K&53a 


iO 


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Eibrarp 


The  Students*  Quiz  Series. 


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PRACTECE  OF  MEDICINE,  including  Ner- 
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vilie  Dispensary  and  Hospilal,  N.  Y. 
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LEA  BROTHERS  &  CO.,  PUBLISHERS.  PHILADELPHIk. 


Th^  Students'  Quiz  Scries. 


OBSTETEICS. 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 


BY 


CHAKLES  W.  HAYT,  M.  D., 

House  Physician,  Nursery  and  Child's  Hospital,  New  York. 


SERIES   EDITED  BY 

BERN   B.  GALLAUDET,  M.D., 

Demonstrator  of  Anatomy,  College  of  Physicians  and  Surgeons,  New  York ;  Visiting 
Surgeon  Bellevue  Hospital,  New  York. 


PHILADELPHIA: 
LEA   BROTHERS   &   CO. 


Entered  according  to  Act  of  Congress,  in  the  year  1892,  by 

LEA  BROTHERS  &  CO., 

In  the  OflBce  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


T?s-s-3/ 

//33 


Westcott  a  Thomson,  William  J.  Dornan, 

Stereotypers  and  Electrotypers,  Philada.  Printer,  Fhilada. 


PREFACE. 


In  the  writing  of  this  Compend  the  object  sought  has  been  to 
place  before  the  student  the  most  important  matter  in  the  subject 
of  Obstetrics  in  as  condensed  a  manner  as  possible.  Much  has 
been  omitted  in  the  way  of  theories  and  obscure  or  disputed 
points,  which  are  appropriate  only  in  an  extended  textbook. 

Brief  manuals  have  a  position  of  unquestionable  value  to  the 
student  and  practitioner,  provided  the  text  is  clear,  accurate,  and 
well  proportioned  to  the  importance  of  the  many  subjects  neces- 
sary to  a  practical  comprehension  of  the  whole.  These  requisites 
have  been  borne  in  mind  in  the  preparation  of  the  present  volume. 

In  its  compilation  the  following  works  have  been  consulted,  as 
well  as  notes  taken  at  the  lectures  of  Dr.  James  W.  McLane  of 
the  College  of  Physicians  and  Surgeons,  New  York  City  :  Char- 
pentier's  Cydrypmdia  of  Ohstetrica  and  Gynecology^  Hirst's  System 
of  Obstetrics^  Playfair.  Winckel,  Lusk,  and  King. 

The  illustrations  are  taken  from   Playfair  and  King. 

CHAS.  W.  HAYT.  M.  D. 

571  Lexington  Ave.,  ^ 
New  York  City.        / 


CONTENTS. 


CHAPTER  I. 

FEMALE  ORGANS  OF  GENERATION. 

PAGE 

External :  Mons  Veneris ;    Labia  Majora ;    Labia   Minora ;   Clitoris ; 

Vestibule  ;  Meatus  Urinarius  ;  Hymen  ;  Vagina  ........      17 

Internal:  Uterus  or  Womb  ;  Fallopian  Tubes  or  Oviducts  ;  Ovaries     .      19 

The  Pelvis  :  Formation  ;  Description  of  the  Pelvis  ;  DifFerence  between 
the  True  and  False;  Diameters;  Planes;  Difference  between  the 
Male  and  Female  ;  Ligaments  ;  Joints  of  the  Pelvis 20 

The  Breasts  :  Described 22 

CHAPTER  11. 

THE    GRAAFIAN  FOLLICLE,  OVULATION,  AND   MENSTRUATION. 

The  Graafian  Follicle:  Structure;  Tunica  Propria;  Tunica  Fibrosa; 
Zona  Pellucida ;  Germinal  Vesicle ;  Germinal  Spot ;  The  Ovule, 
etc 23 

Ovulation  and  Menstruation :  Puberty ;  Changes  occurring  when  Pu- 
berty is  Reached  ;  Nubility  ;  the  Menopause  ;  Ovulation  defined  ; 
Menstruation  defined  ;  Relation  between  the  Two  ;  Corpus  Luteum.      24 

CHAPTER  III. 

PREGNANCY. 

Conception  and  Generation  :  The  Semen  ;  Sterility  ;  Changes  occurring 
in  Impregnated  Ovumj  Changes  in  Uterine  Mucous  Membrane; 
Development  of  Ovum ;  Umbilical  Vesicle;  Allantois;  Amnion; 
Liquor  Amnii;  Chorion;  Placenta;  Umbilical  Cord      26 

The  Foetus :  Described  at  end  of  First,  Second,  Third,  Fourth,  Fifth, 
Sixth,  Seventh,  Eighth,  and  Ninth  Months ;  Vernix  Caseosa ;  the 
Foetal  Head  ;  Functions  of  Foetus  in  Utero ;  Circulation    ....      31 

5 


f)  CONTENTS. 

PAGE 

Phenomena  of  Pregnancy:  Changes  in  Generative  Organs;  Changes 
in  Pelvis ;  Changes  in  Cutaneous  System ;  Blood ;  Respiratory 
Apparatus ;  Digestive  Apparatus ;  Urinary  Organs ;  Osseous  Sys- 
tem ;  and  Nervous  System 36 

Signs,  Symptoms,  and  Diagnosis  of  Pregnancy :  Palpation ;  Positive 
Signs ;  Difference  between  First  and  subsequent  Method  of  Exam- 
ining the  Pregnant  Woman  ;  Duration  of  Pregnancy 39 

Differential  Diagnosis  of  Pregnancy  :  Death  of  Foetus  in  Utero    ...  44 
Disorders   of  Pregnancy:    Classified;    Causes,    Diagnosis,   Prognosis, 

Symptoms,  and  Treatment  of  each      46 

Diseases  occurring  with  Pregnancy 56 

Extra-uterine  Pregnancy  :  Tubal ;  Abdominal  Missed  Labor     ....  57 

Multiple  Pregnancy  :  Superfoetation  and  Superfecundation 60 

Diseases  of  the  Ovum,  Foetus,  and  Decidua  :  Moles      61 

Abortion,  Miscarriage,  and  Premature  Labor 66 

Hemorrhages  of  Pregnancy  :  Accidental ;  Placenta  Pra^via 69 

CHAPTER  IV. 

LABOR. 

Phenomena :  Duration  of  Labor 74-77 

Presentation  and  Position 78 

Mechanism  in  Vertex  Cases 78 

Abdominal  Palpation 82 

Diagnosis  of  Vertex  Presentations 84 

Management  of  Natural  Labor 84 

Anresthesia.  Analgesia 89 

The  Perineum 91 

Episiotomy 93 

The  Puerperal  State 93 

Care  of  the  Infant 96 

CHAPTER  V. 

UNNATURAL  LABORS. 

Persistent  Occipito-posterior  Positions 97 

Face  Presentations 97 

Pelvic  Presentations > 101 

Difficult  Breech  Presentations 107 

Trunk  Presentations 109 


CONTENTS.  7 

PAGE 

Complex  Presentations ,    „ 113 

Prolapse  of  the  Funis      ,    ...... 114 

Anomalies  of  the  Forces  in  Labor , 116 

Anomalies  of  the  Soft  Parts  in  Labor 119 

Anomalies  of  the  Pelvis  in  Labor    ...    =    ,.,., 123 

Anomalies  of  the  Foetus =    .....,...,,..  132 

CHAPTER  yi. 

HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

Hemorrhages  during  and  after  Delivery      -...».....,..  135 

Inversion  of  the  Uterus 139 

Rupture  of  the  Uterus 141 

Accidents  to  Mother,  and  Sudden  Death     ..o    .........    .  143 

CHAPTER  VII. 

OBSTETRIC  OPERATIONS. 

The  Induction  of  Abortion  and  Premature  Labor 145 

Version 148 

The  Forceps:  TheVectis;  The  Fillet 155 

Embryotomy  and  Craniotomy    .....    = 161 

The  Csesarean  Section  and  its  Modifications  :  Laparo-elytrotomy ;  Sym- 
physiotomy; Transfusion;  Infusion 164 

CHAPTER  VIIL 

PUERPERAL  DISEASES. 

Puerperal  Infection 169 

Phlegmasia  Alba  Dolens     ..-,..,........ 175 

Insanity      -....,,...,.,,  176 

Affections  of  the  Nipples  and  Breasts      .....    .    =    .,,..,  178 

CHAPTER  IX. 

THE  INFANT. 

Resuscitation  of  Asphyxiated   Infant;   Nursing  and  Weaning;    Dis- 
eases of  the  Newborn , 181 


OBSTETRICS. 


CHAPTER   I. 
FEMALE  ORGANS  OF   GENERATION. 

>7ame  and  describe  the  external  organs  of  generation. 

They  are  organs  essentially  intended  for  copulation,  and  consist  of — 

1.  The  Mons  Veneris^  which  is  a  firm  cushion-hke  eminence  above  the 
pubes,  composed  of  skin,  fat,  connective  tissue,  blood-vessels,  and  nerves. 
It  has  many  sebaceous  and  sweat-glands  upon  it,  and  is  covered  with 
hair.  Its  use  is  as  a  cushion  for  the  male  during  copulation  and  to  pre- 
vent injury  from  blows.     There  is  no  mons  until  puberty  (Fig.  1,  /). 

2.  The  Labia  Majora  are  the  external  or  great  lips.  They  are  two 
folds  of  skin  extending  from  the  median  line  of  the  mons  veneris  ante- 
riorly, to  terminate  posteriorly  in  what  is  called  the  fourchette,  which  is 
situated  at  the  anterior  portion  of  the  perineum,  and  is  nearly  always 
torn  at  the  first  labor.  They  are  made  up  of  adipose  tissue,  blood-ves- 
sels, and  nerves,  and  have  both  a  cutaneous  and  mucous  covering. 
Deeply  within  them  are  situated  the  vulvo-vaginal  glands.  In  the  vir- 
gin the  labia  majora  are  in  apposition,  but  after  childbirth  they  become 
more  or  less  separated  (Fig.  1,  a). 

3.  The  Labia  3Iinora,  or  Nymphae,  are  the  internal  or  lesser  lips. 
They  are  two  moist  folds  of  mucous  membrane  seen  in  separating  the 
labia  majora.  They  arise  by  two  roots.  The  superior  pair  are  thick  and 
fleshy,  and  together  form  the  hood  or  prepuce  of  the  clitoris.  The  in- 
ferior pair  are  thin,  and  form  the  frenum  of  the  clitoris.  In  very  young 
children  the  nymphae  project  be.yond  the  vulva  (Fig.  1,  &). 

4.  The  Clitoris  is  a  reddish  tubercle  situated  about  half  an  inch  be- 
hind the  anterior  commissure  of  the  labia  majora.  It  is  made  up  of  the 
glans  clitoridis  and  the  two  corpora  cavernosa,  which  are  separated  from 
each  other  by  a  fibrous  septum.  The  nerve-supply  is  large,  and  on  this 
account  it  is  supposed  to  be  the  chief  seat  of  voluptuousness  in  the 
female  (Fig.  1,  d). 

^  5.  The  Vestibule  is  a  triangular  surface  bounded  by  the  nj^mphae  on 
either  side  and  the  clitoris  above  (Fig.  1,  c). 

2— Obs.  17 


18 


FEMAI^E  ORGANS  OF  GENERATION. 


6.  The  Meatus  Uriimrhis  is  the  external  orifice  of  the  urethra,  and  is 
situated  at  the  base  of  the  vestibule.  Immediately  below  it  is  a  small 
tubercle  which  terminates  the  superior  wall  of  the  vagina.  This  arrange- 
ment allows  the  meatus  to  be  found  on  examination  without  exposing 


^^r'Cy 


External  Organs  of  (Jeneratii^n  ;  a,  labium  inajus;  6,  labium  minus;  c,  vestibule  above 
urethral  orifice;  d,  glans  clitoridis;  e,  preputium  clitoridis  ;  /,  mons  veneris. 

the  woman.  After  confinement,  however,  the  swelling  of  the  parts 
sometimes  renders  the  finding  of  this  tubercle  difficult,  and  makes  cathe- 
t(!rizati()n  not  easy  even  though  the  genitals  be  exjiosed.  For  this  reason 
the  best  and  proju'r  proc('(lurc  is  to  sei>arate  the  labia  with  the  thumb 
and  index  finger  and  introduce  the  catheter  by  sight. 


INTERNAL.  19 

Y.  The^  Hx/mfM  is  situated  at  the  orifice  of  the  vagina,  and  is  formed 
from  vaginal  mucous  membrane.  It  contains  a  vanable-sized  opening 
through  which  passes  the  menstrual  fluid.  After  the  first  labor  three  or 
four  eminences  are  left  which  are  called  "carunculse  myrtiformes. " 

8.  The  Vagina  is  a  musculo-membranous  canal  lying  wholly  within 
the  true  pelvis,  and  extending  from  the  vulvar  orifice  to  the  uterus.  It 
is  in  relation  anteriorly  with  the  bladder  and  posteriorly  with  the  rectum. 
Its  length  varies,  the  anterior  wall  averaging  from  2|  to  3  inches,  the 
posterior  from  3  to  SJ  inches.  It  is  made  up  of  three  laj^ers— an  exter- 
nal or  cellular,  middle  or  muscular,  and  internal  or  mucous  coat.  This 
latter  is  thrown  into  numerous  folds  or  rugae,  which  become  greatly  atro- 
phied in  multiparge  and  the  aged,  but  never  entirely  disappear.  In  the 
virgin  the  anterior  and  posterior  walls  are  in  apposition. 

What  constitute  the  internal  organs  of  generation?     Describe 
each. 

l._  The  Uterus,  or  Womh,  is  situated  in  the  true  pelvis,  above  the 
vagina  and  between  the  bladder  in  front  and  the  rectum  behind.  It  is 
the  organ  in  which  the  fecundated  ovule  is  developed,  and  which  expels 
the  foetus  when  the  term  of  pregnancy  arrives.  The  adult  nulliparous 
uterus  is  about  3  inches  long,  2  inches  broad  at  the  fundus,  and  1  inch 
thick.  Its  weight  is  from  7-12  drachms.  It  is  divided  into  three  re- 
gions :  the  fundus,  being  that  part  above  the  Fallopian  tubes ;  the  body, 
between  the  tubes  and  the  os  internum  ;  the  cervix  or  neck,  extending 
from  the  os  internum  to  the  os  externum.  It  presents  two  surfaces  and 
two  borders,  and  is  made  up  of  three  coats :  first,  an  external  or  perito- 
neal ;  second,  the  middle  or  muscular  layer,  which  consists  of  unstriped 
muscular  fibre  ;  and  third,  an  internal  lining  of  mucous  membrane  (also 
called  musculus  granulosus),  which  terminates  below  at  the  internal  os. 
It  is  held  in  position  by  the  vagina  below,  two  vesico-uterine  ligaments 
anteriorly,  two  recto -uterine  hgaments  posteriorly,  two  broad  ligaments 
laterally,  and  two  round  ligaments  passing  from  the  superior  angle  of 
the  uterus  to  the  labia  majora. 

2.  The  Fallopian  Tubes,  or  Oviducts,  are  two  trumpet-shaped  tubes 
from  4  to  5  inches  in  length,  passing  from  the  superior  angles  of  the 
uterus  to  the  ovaries.  Through  these  ducts  the  semen  is  brought  in  con- 
tact with  the  ovule  and  the  ovule  is  earned  into  the  cavity  of  the  uterus. 
They  also  are  composed  of  three  coats — an  external  serous,  middle  mus- 
cular, and  internal  mucous. 

3.  The  Ovaries,  the  geiTn-producing  organs  of  the  female,  are  two 
small  ovoid  bodies  situated  on  either  side  of  the  uterus  in  the  poste- 
rior fold  of  the  broad  ligament  and  at  the  end  of  the  Fallopian  tubes. 
Their  size  and  weiglit  vary  with  age,  but  in  general  the  dimensions  are 
Hxf  Xi  inch,  and  they  weigh  about  90  grains.  The  ovary  consists  of 
a  spongy,  reddish  mass  called  the  stroma  or  medullary  portion.  This  is 
niade  up  of  connective  tissue,  muscular  fibres,  and  vessels.  Externally, 
it  is  thicker,  more  compact,  of  a  whitish  color,  and  is  called  the  '"tunica 


20  FEMALE   ORGANS   OF   GENERATION. 

albuginea."    This  is  covered  by  an  epithelial  layer  derived  from  the 
peritoneum. 

THE  PELVIS. 

What  is  the  pelvis,  and  how  is  it  made  up? 

The  Pelvis  is  a  bony  basin  situated  at  the  lower  part  of  the  trunk.  It 
rests  below  upon  the  femurs,  supports  the  vertebral  column,  and  forms  a 
canal  through  which  the  child  passes  to  be  delivered  from  the  uterus  of 
the  mother.  It  is  formed  of  four  bones — the  sacrum,  coccyx,  and  two 
innominate  bones. 

Name  the  ligaments  connected  with  the  pelvis. 

Two  anterior  sacro-iliac  ligaments  connecting  the  anterior  surfaces  of 
the  sacrum  and  ilia ;  two  posterior  sacro-iliac  ligaments  between  the 
sacrum  and  ilia  posteriorly ;  two  great  sacro-sciatic  ligaments  passing 
from  the  sacrum  and  ilium  to  the  ischium  ;  two  lesser  sacro-sciatic  liga- 
ments passing  from  the  ischium  to  the  sacrum  and  coccyx ;  anterior, 
posterior,  and  lateral  sacro-coccygeal  ligaments  between  the  sacrum  and 
coccyx ;  anterior,  posterior,  and  superior  pubic  and  subpubic  ligaments 
between  the  two  pubic  bones. 

State  what  is  understood  by  the  true  pelvis. 

The  true  pelvis  is  that  jiart  of  the  pelvic  cavity  situated  below  the 
ilio-pectineal  lines.  This  is  in  contradistinction  to  the  false  pelvis,  which 
is  the  broad  expanded  portion  above  these  lines,  and  is  of  practically  no 
importance  from  an  obstetrical  point  of  view.  The  upper  opening  of  the 
true  pelvis  is  called  the  superior  strait,  inlet,  or  brim,  and  is  heart- 
shaped  ;  the  lower  opening  is  called  the  outlet  or  inferior  strait,  is  some- 
what oval,  and  is  bounded  by  the  tuberosities  of  the  ischia,  the  coccyx, 
and  rami  of  the  pubes. 

"What  are  the  diameters  of  the  pelvis  ? 

They  are  measurements  taken  between  various  points  directly  opposite 
each  other,  and  are  three  in  number:  1st,  the  antero-post^rior  or  con- 
jugate ;  2d,  the  oblique ;  3d,  the  transverse.  The  conjugate  at  the  brim 
is  4  inches,  and  is  taken  from  the  centre  of  the  promontory  of  the  sacrum 
to  the  posterior  siu'face  of  the  symphysis.  At  the  outlet  this  diameter 
is  5  inches.  The  measurement  here  is  taken  from  the  tip  of  the  coccyx 
to  the  lower  border  of  the  symphysis  (Fig.  2,  1). 

The  oblique  is  Al  inches  both  at  the  brim  and  at  the  outlet.  At  the 
brim  this  measurement  is  taken  from  the  sacro-iliac  synchondrosis  of  one 
side  to  the  ilio-ixictineal  eminence  of  the  other;  at  the  outlet,  from  the 
centre  of  the  .ureat  sacro-sciatic  ligament  to  the  point  of  junction  of  the 
ascendiny;  ramus  of  the  ischium  with  the  descending  of  the  pubis  (Fig. 
2.3). 

The  transverse  is  5  inches  at  the  inlet,  and  is  the  measurement  from  a 
point  midway  between  the  sacro-iliac  joint  and  the  ilio-pectineal  eminence 
to  a  con-esponding  point  on  the  o])posite  side  (Fig.  2,  2).     At  the  outlet 


THE    PELVIS. 


21 


this  diameter  is  4  inches,  and  is  the  distance  between  the  tuberosities  of 

Fig.  2. 


The  Pelvis:  1,  Antero-posterior  or  Conjugate  Diameter;  2,  Transverse;  3,  Oblique. 

the  ischia.     (There  are  a  few  other  measurements  sometimes  given,  but 
they  are  of  httle  importance,  and  therefore  are  omitted. ) 

How  many  true  planes  are  there  in  the  pelvis  ?    Name  them  and 
give  their  direction. 

There  are  four — two  anterior  and  two  posterior  "  z';2c?/»erZ"  planes. 
The  anterior  have  a  direction  from  above  downward,  from  behind  for- 
ward, and  from  without  inward ;  the  posterior  from  above  downward, 
from  before  backward,  and  from  without  inward. 

What  are  the  differences  between  the  male  and  female  pelvis? 
The  real  differences  are  found  in  the  true  pelvis,  and  are  determined 
'by  the  presence  of  the  uterus. 


Female. 

Shallow,  but  capacious. 

Light  in  structure,  and  the  points 

for   muscular    attachments    are 

much  less  developed. 
Subpubic  angle  75°. 


Male. 

Deep. 

Bones  stronger,  heavier,  rougher, 
and  more  compact. 


Pelvis  more  conical.  Sacrum  less 
concave.  Ischial  tuberosities 
closer  together.  Subpubic  angle 
more  acute,  58°. 

What  alterations  take  place  in  the  pelvis  during  pregnancy? 

The  cartilages  become  softened  and  swollen  and  the  ligaments  relaxed. 
This  makes  the  pelvis  more  spacious. 


22 


THE    BREASTS. 


Fig.  3. 


THE   BREASTS. 

Describe  the  mammary  glands  or  breasts. 

The  Mdiuma',  or  breasts,  are  two  glandular  organs  connected  with  the 
generative  apparatus,  which  secrete  the  fluid  destined  to  nourish  tlie 
child.     They  are  situated  on  the  anterior  and  superior  part  of  the  chest, 

in  front  of  the  pectoralis  major  and  be- 
tween the  third  and  seventh  ribs.  They 
are  conical  or  hemispherical  in  shape  in 
the  nulliparous  woman,  but  vary  greatly 
both  in  size  and  form  in  w^omen  who 
have  nursed.  Anomalies  in  position  are 
sometimes  observed. 

The  external  surface  has  three  zones: 
( 1 )  A  white  peripheral  zone,  smooth 
and  soft,  reaching  from  the  periphery 
to  the  areola.  (2)  An  areolar  zone  ex- 
tending to  the  nipple.  This  is  of  a  pink 
or  rosy  hue  in  blonds ;  in  brunettes 
nearly  brown.  During  pregnancy  this 
zone  becomes  dark  and  pigmented.  (3) 
The  nipple,  or  "teat,"  a  large  papilla 
situated  at  the  summit  of  the  gland. 

The  mammae  are  made  up  of  gland- 
tissue  and  fat.  Each  gland  contains  fif- 
teen or  twenty  lobes  sejiaratcd  by  fibrous 
septa  and  by  adipose  tissue.  The  lobes 
are  subdivided  into  lobules,  which  are 
produced  by  the  aggregation  of  acini, 
in  which  the  milk  is  formed.  As  the 
ducts  of  the  lobes  approach  the  nipple 
they  become  widely  dilated,  so  as  to 
form  small  reservoirs  in  which  milk  ig 
stored.  But  as  they  pass  through  the  nipple  they  again  contract.  The 
breast  receives  a  large  num})er  of  both  sui)erficial  and  deep  vessels  and 
nerves,  and  its  sympathetic  relations  with  the  uterus  are  very  strongly 
marked,  as  is  shown  after  delivery  by  the  fact  that  the  nursing  of  the 
child  produces  reflex  contractions  of  the  uterus  and  sometimes  severe 
after-pains. 


1,  Galactophorous  Ducts;   2,  Lobuli 
of  tne  Mauiinarv  (Jland. 


THE   GRAAFIAN    FOLLICLESc 


23 


CHAPTER   II. 

THE   GRAAFIAN   FOLLICLES,   OVULATION,   AND  MENSTRU- 
ATION. 


THE   GRAAFIAN  FOLLICLES. 
What  are  the  Graafian  follicles? 

The.y  are  small  spherical  vesicles  situated  in  the  stroma  of  the  ovary. 
At  the  age  of  about  twenty  there  are  some  350,000  to  each  ovary.  From 
tliis  time  on  they  steadily  decrease  in  number.  They  are  formed  of  two 
membranes — the  external,  very  vascular  and  made  up  of  connective  tis- 
sue called  the  "tunica  fibrosa;"  the  internal,  composed  of  connective 


Diagram  of  a  Triaugular  Portion  cut  from  the  stroma  of  the  Ovary:  1,  epithelial  cover- 
ing of  ovary  ;  2,  tunica  albuginea;  3,3,  ovarian  stroma;  4,  tunica  propria  of  5,  Graafian 
follicle;  6,6,  membrana  granulosa;  7,  liquor  folliculi;  S,  zona  pellucida;  9,  yelk;  10. 
germinal  vesicle;  11,  germinal  spot  (King). 

tissue  called  the  "tunica  propria."  The  inner  surface  of  the  latter  is 
lined  with  a  layer  of  small  round  nucleated  cells,  the  "membrana  granu- 
losa." These  cells  become  denser  at  one  point,  and  form  the  "discus" 
or  "cumulus  proligerus."  The  cavity  of  the  follicle  is  filled  with  a  clear, 
viscid  liquid,  the  "  liquor  folliculi." 


24  OVULATION    AND    MENSTRUATION. 

Describe  the  contents  of  the  Graafian  follicle. 

Tlie  Graafian  follicle  contains,  besides  the  liquor  folliculi,  a  small  body 
about  y^5  of  an  inch  in  diameter,  the  "ovule."  This  is  surrounded  by 
the  cells  forming  the  discus  proligerus,  and  its  envelope  is  a  thick,  elas- 
tic, transparent  membrane,  which  has  been  termed  the  vitelline  mem- 
brane or  zona  pellucida.  The  cavity  of  the  ovule  is  filled  with  a  granular 
liquid,  the  "  vitellus,"  or  yelk,  in  which  is  found  the  vesicle  of  Purkinje, 
or  germinal  vesicle,  containing  the  germinal  spot.  From  without  inward 
we  thus  find — (1)  the  tunica  fibrosa;  (2)  the  tunica  propria;  (3)  the 
membrana  granulosa ;  (4)  the  discus  proligerus;  (5)  the  liquor  follicuh 
(these  compose  the  Graafian  follicle);  (6)  the  zona  pellucida;  (7)  the 
yelk ;  (8)  the  germinal  vesicle ;  (9)  the  germinal  spot,  the  ovule  (Fig.  4). 

OVULATION   AND  MENSTRUATION. 
What  is  puberty? 

Paherty  is  the  period  of  transformation  from  childhood  to  youth,  and 
is  the  time  when  fecundation  is  rendered  possible.  This  period  varies 
considerably  in  different  climates  and  individuals,  but  averages  twelve 
years  in  females  and  fourteen  in  males. 

Describe  briefly  the  changes  occurring  in  the  female  when  pu- 
berty is  reached. 

The  pubis  becomes  covered  with  hair,  the  pelvis  wider,  the  thighs 
broader,  and  the  breasts  larger.  The  character  also  changes  materially. 
This  transformation  is  indicated  by  the  appearance  of  two  functions  car- 
ried on  by  the  female  generative  organs — namely,  ovulation  and  men- 
struation. 

What  is  nubility? 

Niihility  is  the  age  when  fecundation  is  rendered  possible,  and  the 
consequence  borne  normally  without  damage.  It  is  generally  considered 
the  period  of  puberty,  but  this  is  erroneous,  since,  thougli  puberty  must 
precede  it,  a  girl  may  be  pubescent  without  being  nubile. 

What  is  the  menopause  ? 

The  iMenopaiise,  or  change  of  life,  is  the  time  when  menstruation  ceases. 
Like  puberty,  the  menopause  occurs  at  a  very  variable  period  of  life,  the 
average  being  at  the  forty-third  or  forty-fourth  year,  though  cases  have 
been  known  in  which  menstruation  lasted  until  the  sixty-fifth  year.  The 
menopause  has  been  known  to  occur  as  early  as  twenty-eight.  It  does 
not  take  place  suddenly,  but  begins  by  irregularities  in  the  flow  in  regard 
to  duration,  quality,  and  quantity,  and  at  last  the  flow  ceases  altogether. 
x\t  the  same  time  some  general  ailments  appear  and  the  genital  organs 
become  atrophied. 

What  is  understood  by  the  term  "  ovulation  "  ? 

By  Orulatioit  we  mean  the  ])lienom(M)a  accompanying  the  formatioti 
of  the  ova  in  the  ovary,  the  rupture  of  the  Graafian  follicle,  and  the  dis- 


OVULATION   AND    MENSTKUATION.  25 

charge  of  the  ovum  from  the  vesicle.  This  last  is  followed  by  the  mi- 
gration of  the  ovum  through  the  tube,  the  cicatrization  of  the  Graafian 
follicle,  and  the  production  of  the  corpus  luteum. 

What  does  the  term  "menstruation"  mean? 

Menstruation  is  the  periodical  discharge  of  blood  and  mucus  from  the 
female  organs  of  generation,  generally  occurring  every  lunar  month,  ex- 
cepting during  pregnancy  and  lactation,  when  it  is  usually  suppressed. 
This  function  is  established  at  puberty  and  ceases  at  the  menopause. 

The  menstrual  blood  is  acid  in  reaction,  has  a  slight  odor,  is  prevented 
from  coagulating  by  the  mucus  contained  in  it,  and  varies  greatly  in 
amount  in  different  individuals.  The  source  of  the  blood  is  the  mucous 
membrane  lining  the  uterus.  The  purpose  of  the  menstrual  flow  is  sim- 
ply to  prepare  a  germ-bed  for  the  reception  of  the  impregnated  ovum. 

What  is  the  relation  between  ovulation  and  menstruation? 

The  flow  probably  begins  with  the  rupture  of  the  Graafian  follicle,  and 
continues  a  variable  number  of  days,  ordinarily  about  four.  Undoubt- 
edly, ovulation  may  take  place  without  its  outward  manifestation  (men- 
struation), as  many  cases  are  recorded  where  impregnation  has  occurred 
during  lactation  and  before  menstruation  had  been  re-established.  How- 
ever, they  usually  go  together. 

What  is  the  corpus  luteum? 

The  Corpus^  Luteitm  is  a  small  yellowish  mass  left  in  the  ovary  after 
the  rupture  of  one  of  the  Graafian  follicles.  It  was  once  supposed  to  be 
a  sign  of  previous  impregnation,  but  is  found  in  unquestionable  virgins. 

Describe   the   corpus   luteum   when   pregnancy   has   not   taken 
place. 

When  a  Graafian  follicle  is  about  to  rupture,  a  short  time  before  the 
menstrual  flow  begins,  it  increases  in  size  and  approaches  the  surface  of 
the  ovary  until  it  forms  a  projection  upon  it.  The  distension  is  due  to 
an  increase  of  its  contained  fluid.  Now,  an  escape  of  blood  from  the 
distended  capillaries  of  its  inner  coat  occurs,  and  the  follicle  ruptures,  as 
does  also  the  ovarian  covering ;  the  ovule  passes  to  the  surface  of  the 
ovary  and  into  the  fimbriated  extremity  of  the  Fallopian  tube.  The 
internal  layer  of  the  follicle  now  becomes  the  seat  of  an  hypertrophy 
due  to  the  development  of  the  cells  which  compose  its  tissues.  The 
edges  of  the  rent  in  the  internal  layer,  on  account  of  this  hypertrophy, 
come  in  contact ;  the  external  la.yer,  being  elastic,  retracts,  and  the  cor- 
pus luteum  results.  The  vessels  now  begin  to  disappear,  the  cells  to 
vanish,  and  the  whole  mass  is  reduced  to  a  small  cicatrix,  which  gen- 
erally disappears  in  from  thirty  to  forty  days  (Longet). 

Describe  the  corpus  luteum  when  pregnancy  has  taken  place. 

All  of  the  above  changes  occur,  excepting  in  a  more  marked  degree. 
Instead  of  disappearing  in  thirty  or  forty  days,  as  is  the  case  when  im- 


2fi  PREGNANCY. 

pregnation  does  not  occur,  they  go  until  the  fourth  month  of  pregnancy, 
when  tliey  attain  their  maximum  development  and  form  a  corpus  luteum 
which  averages  ]  inch  in  length  and  j  an  inch  in  breadth.  This  now 
commences  to  atroph}^,  and  cicatrization  becomes  complete  a  few  weeks 
after  delivery. 


CHAPTER  III. 
PREGNANCY. 


CONCEPTION   AND   GENERATION. 

What  is  conception  ? 

Conception^  impregnation  or  fecundation,  is  the  act  by  which  the 
semen  or  fluid  furnished  by  the  male  organs  of  generation  unites  with 
the  ovule  from  the  female  ovary,  so  that  a  new  being  results.  This 
may  take  place  in  some  part  of  the  Fallopian  tube. 

What  must  take  place  for  fecundation  to  occur? 

There  must  be  a  connection  of  the  two  sexes  by  copulation,  and  there 
must  be  ovulation  by  the  female  and  an  emission  of  semen  by  the  male. 

Describe  the  semen,  and  explain  how  its  ascent  to  reach  the 
ovule  is  accomplished. 

The  semen  is  a  white,  viscid,  dense  fluid,  having  a  faint  odor,  secreted 
by  the  testicles  of  an  adult  male,  and  thrown  into  the  urethra  by  the 
ejaculatory  ducts.  It  consists  of  water,  albuminous  matter,  salts  of  lime 
and  soda,  and  contains  numerous  peculiar  organisms  called  spermatozoids. 
These  spermatozoids  form  the  essential  fecundating  part  of  the  semen, 
are  about  (y^oth  of  an  inch  in  length,  and  resemble  the  tadpole  of  the  frog. 
They  are  made  up  of  three  parts,  a  head,  body,  and  tail,  and  are  ani- 
mated by  very  rapid  movements.  When  placed  in  proper  surroundings 
they  retain  their  vitality  for  a  considerable  time  after  emission.  Exces- 
sively acid  or  alkaline  fluids  and  alcohol  destroy  them ;  heat  and  cold 
stop  their  movements;  the  normal  temperature  of  the  body  and  the 
menstrual  discharge  increase  these  movements.  The  ascent  of  the  se- 
men is  mainly  due  to  the  inherent  mobility  of  the  spermatozoids. 

State  some  of  the  most  common  causes  of  sterility. 

In  the  male : 
All  that  hinders  or  alters  the  act  of  copulation  ; 
Absence  of  ejaculation ; 

Absence  of  spermatozoids  in  the  semen,  )    n^^  disease  ■ 

Inactivity  of  the  spermatozoids  in  the  semen,  j  -^  '        ' 

Abnormal  formation  of  external  genitals,  |  H^j^pJ^'spadias,  etc. 


CONCEPTION    AND   GENERATION.  27 

In  the  female : 

Abnormal  formation  of  the  genitais ; 

Displacements  of  the  uterus,  obstructing  the  ascent  of  the  semen ; 

Vaginal  or  uterine  secretions  rendered  so  strongly  acid  or  alkaline  by 
disease  that  the  spermatozoids  are  destroyed  ; 

Tubal  and  ovarian  diseases. 

Describe  the  changes  which  take  place  in  the  impregnated  ovum 
during  its  passage  to  the  uterus. 

As  the  ovule  escapes  from  the  ovary  it  takes  with  it  some  particles  of 
the  discus  proligerus,  which  surround  it  as  a  thin  layer  of  granular  cells. 
B}'^  friction  with  the  sides  of  the  tube  these  disappear,  and  the  zona  pel- 
lucida  is  the  outermost  covering.  It  has  now  advanced  some  distance 
along  the  tube,  and  becomes  invested  with  a  covering  of  albuminous 
material.  During  this  time  the  vitellus  or  yelk  shrinks  from  its  covering 
and  the  germinative  vesicle  disappears.  The  first  indication  of  impreg- 
nation occurs  when  a  small,  clear  vesicle  appears  in  the  centre  of  the 
yelk.  This  is  called  the  "vitelline  nucleus,"  and  is  found  in  fifteen  to 
thirty  hours  after  fecundation.  Now  what  is  called  segmentation  of  the 
yelk  takes  place.  This  consists  in  a  breaking  up  of  the  vitellus.  First. 
the  vitelline  nucleus  divides  into  two  nuclei,  and  then  the  yelk  into  two 
halves.  The  process  continues:  the  two  new  cells  are  converted  into 
four,  the  four  into  eight,  and  so  on  until  a  great  number  are  generated. 
This  forms  a  granular  mass  which  from  its  resemblance  to  a  mulberry  is 
called  the  "  muriform  body  "  or  "  morula."  A  clear  fluid  then  accumu- 
lates in  the  centre,  expanding  the  muriform  body  and  pushing  tlie  cells 
together  until  their  edges  meet,  forming  an  internal  lining  to  the  zona 
pellucida.  This  is  the  "blastodermic  membrane,"  and  from  it  the  foetus 
is  developed.  The  ovum  is  now  2Vth  of  an  inch  in  diameter,  and  has 
occupied  about  twelve  days  in  its  passage  from  the  ovary  to  the  uterus, 
which  it  has  reached. 

What  changes  occur  in  the  uterine  mucous  membrane  to  prepare 
it  for  the  reception  of  the  impregnated  ovum  ? 

At  each  menstrual  period  the  mucous  membrane  of  the  uterus  be- 
comes thickened  and  vascular,  and  when  fecundation  has  occurred  this 
change  is  much  more  marked,  until  the  result  is  the  formation  of  a  dis- 
tinct membrane  which  has  received  the  name  of  the  "decidua."  This 
has  three  divisions:  (1)  The  "decidua  vera."  lining  the  entire  uterine 
cavity,  and  undoubtedly  the  hypertrophied  mucous  membrane  of  the 
uterus.  (2)  The  "  decidua  reflexa,"  which  surrounds  the  ovum,  and  is 
probably  simply  a  growth  of  the  decidua  vera  around  the  ovum  at  the 
point  where  it  lies  in  the  uterus.  As  the  ovum  grows  this  naturally 
stretches  until  it  eventually  (at  the  fourth  month)  comes  in  contact  all 
around  with  the  decidua  vera.  (3)  The  "decidua  serotina,"  which  is 
that  part  of  the  decidua  vera  on  which  the  ovum  rests.  At  this  point 
the  placenta  is  developed.     Thus  it  is  seen  that  the  three  deciduae  be- 


28 


PREGNANCY. 


come  and  really  are  one.  Late  in  pregnancy  fatty  degeneration  of  this 
structure  occurs,  its  adhesions  to  the  uterine  wall  lessen,  and  it  is  thrown 
off  with  the  placenta  after  labor,  leaving  a  new  mucous  membrane  lining 
the  uterus. 

Describe  the  development  of  the  ovum  after  it  has  reached  the 
uterus. 

The  blastodermic  membrane  divides  into  three  parts:    an  external, 
called  the  "epiblast;"    a  middle,  called  the  "mesoblast"  or  "meso- 
derm;"   and   an   internal,    the 


Fig.  5. 


External  Surface  of  Epiblast,  showing  area  ger- 
minativa,  area  pellucida,  and  primitive  trace. 


hypoblast "  or  "  entoderm. ' ' 
At  this  time  a  minute  elevation, 
due  to  an  aggregation  of  cells, 
and  consisting  of  a  slight  thick- 
ening of  the  membrane,  appears. 
This  is  the  "  area  germinativa. " 
In  its  centre  a  faint  line  is  seen, 
"the  primitive  trace"  or  "em- 
bryonic line."  Surrounding  it 
are  a  few  translucent  cells,  which 
have  been  called  the  ' '  area  pel- 
lucida" (Fig.  5).  The  extremi- 
ties of  the  primitive  trace  thicken 
and  turn  upon  themselves — one 
anteriorly,  called  the  cephalic 
or  head  fold ;  one  jwsteriorly, 
the  caudal  or  tail  fold.  The 
body  of  the  embryo  is  now 
visible. 


What  organs  or  parts  of  the  foetus  are  developed  from  the  epi- 
blast? 

The  epiblast  takes  part  in  the  formation  of  the  superficial  layer  of  the 
skin,  hair,  nails,  organs  of  special  sense,  the  brain,  spinal  cord,  and 
amnion. 

What  parts  are  developed  from  the  mesoblast? 

From  the  mesoblast  are  formed  the  bony  framework,  the  muscular 
and  vascular  system,  the  muscular  and  fibrous  tissues  of  the  digestive 
tract,  and  probably  the  genito-urinary  organs. 

What  is  developed  from  the  hypoblast? 

From  the  hypoblast  is  formed  the  ei)ithelium  lining  the  respiratory 
and  digestive  tracts. 

Describe  the  umbilical  vesicle. 
The  Umbilical  Vesicle  is  a  small  round  sac  communicating  with  the 


THE   ALLANTOIS 

Fig.  6.  Fig.  7. 


29 


a,a,  projecting  folds  of  amnion;  z,  zona 
pellucida ;  s,  epiblast ;  »i,  hypoblast ;  w, 
umbiliCHl  vesicle. 


a,a,   folds  of  amnion  about  to  join ;  p, 
commencement  of  allantois. 


abdominal  cavity  of  the  foetus  through  a  constricted  portion  called  the 
"vitelline  duct,"  and  containing  a  yellowish,  oily  fluid  from  which  the 
foetus  derives  its  nourishment 

during  the  first  few  weeks  of  Fig.  8. 

life.  It  attains  its  greatest 
development  by  the  end  of 
the  fourth  week.  From  this 
time  on  it  gradually  shrinks 
until  by  the  sixth  or  seventh 
week  it  has  entirely  disap- 
peared. It  is  formed  from 
the  internal  layer  of  the  blas- 
todermic membrane. 

What  is  the  allantois? 

It  is  a  small  vesicle  derived 
from  the  entoderm  and  inner 
stratum  of  the  mesoderm, 
formed  about  the  twentieth 
day  near  the  caudal  extrem- 
ity of  the  foetus,  and  Ijnng 
between  the  amnion  and  cho- 
rion. It  is  connected  with 
the  bladder  by  the  urachus, 
and  grows  rapidly  until  it  en- 
tirely lines  the  chorion.    This 

contains  the  two  umbilical  arteries  derived  from  the  aorta,  and  two  um- 
bilical veins,  one  of  which  soon  disappears.  Its  caudal  part  helps  to 
form  the  umbilical  cord. 


Further  Development :  o,  junction  of  amniotic 
folds;  p,  pedicle  of  allantois;  ?/,  umbilical 
vesicle. 


30  PREGNANCY. 

Describe  the  amnion. 

The  Amnion  is  the  innermost  of  the  two  membranes  surrounding  the 
foetus.  Externally  it  is  in  contact  with  the  chorion,  internally  with  the 
hquor  amnii  and  foetus.  It  also  forms  a  covering  for  the  umbilical  cord, 
and  is  continuous  with  the  integument  at  the  umbilicus  of  the  foetus.  It 
is  formed  from  the  ei)iblast,  and  secretes  a  fluid  which  distends  its  cav- 
ity.    This  is  called  the  "liquor  amnii,"  and  in  it  the  foetus  floats. 

What  is  the  character  of  the  "liquor  amnii"?  and  what  are  its 
uses? 

It  is,  in  the  early  months  of  pregnancy,  a  clear,  transparent  fluid,  con- 
sisting of  water,  albuminous  matter,  and  various  inorganic  salts.  Later 
it  becomes  denser  and  of  a  brownish  color,  having  a  faint  odor.  It  pre- 
vents injury  to  the  child  from  blows  received  on  the  abdomen  of  the 
mother.  It  also  prevents  injury  to  the  uterus  which  the  foetus  might 
inflict  by  its  movements.  Lastly,  it  acts  as  a  fluid  wedge  which  dilates 
the  OS  during  labor  and  lubricates  the  parturient  canal  for  the  passage 
of  the  child. 

Describe  the  chorion. 

The  Chorion  is  the  more  external  of  the  true  foetal  membranes.  It 
is  a  closed  sac,  formed  by  the  external  layer  of  the  blastodermic  mem- 
brane and  the  zona  pellucida.  Externally  it  is  in  contact  with  the  de- 
cidua.  and  internally  with  the  amnion.  Its  internal  surface  is  smooth 
and  shining,  while  the  external  surface  is  rough,  being  covered  with 
small  villi. 

What  are  the  chorionic  villi? 

They  are  small,  hollow  sprouts  springing  from  the  external  surface  of 
the  chorion  and  burying  themselves  in  the  decidua.  At  first  non-vascu- 
lar, later  (when  the  allantois  has  spread  itself  over  the  whole  of  the 
chorion)  each  villus  receives  an  artery  and  vein,  which  give  branches  to 
the  subdivisions  into  which  the  villi  divide.  Soon  all,  excepting  those  in 
contact  with  the  decidua  scroti na,  begin  to  shrivel  up  and  disappear, 
until  by  the  end  of  the  eighth  week  none  are  left  excepting  at  this  site. 
Occasionally  one  remains  on  the  surface  of  the  chorion,  causing  hemor- 
rhage after  the  birth  of  the  child. 

What  is  the  placenta,  and  how  is  it  formed? 

The  Phicrnfa^  or  after-birth,  whose  function  it  is  to  aerate  the  blood 
of  the  foetus,  is  a  soft,  spongy,  vascular  mass,  circular  in  form  and  thick- 
est at  its  centre.  It  is  from  0  to  9  inches  in  diameter,  from  2  to  1  inch 
thick  in  the  centre,  and  weighs  from  1  to  U  i)ounds  avoirdupois.  It 
begins  to  be  formed  at  the  second  month,  but  docs  not  reach  its  full  de- 
velopment until  the  third  month.  Its  usual  attachment  is  to  some  part 
of  the  uterus  near  one  of  the  Falloi)ian  tubes,  thouirh  it  may  be  situated 
anywhere  within  the  uterine  cavity.  It  is  formed  of  I'rom  fifteen  to 
twenty  tufts  or  villi,  and  has  two  surfaces — an  external  uterine  or  ma- 


THE   FCETUS.  31 

temal,  whicli  is  rough  and  in  contact  with  the  uterine  wall ;  and  an  in- 
ternal or  foetal :  this  is  smooth,  and  covered  by  the  two  membranes,  the 
amnion  and  chorion.  Each  tuft  is  extremely  vascular,  and  its  vessels  lie 
in  close  apposition  with  the  maternal  vessels  within  the  walls  of  the 
uterus. 

What  is  the  umbilical  cord? 

The  Umbilical  Cord  is  the  pedicle  attaching  the  foetus  to  the  placenta. 
It  is^  formed  about  the  fourth  week  of  gestation,  and  consists  of  two 
arteries  and  one  large  vein,  which  pass  in  a  spiral  direction  from  the 
umbilicus  of  the  child  to  some  portion  of  the  placenta,  most  frequently 
about  its  centre.  Surrounding  the  vessels  is  a  soft,  transparent,  gelati- 
nous substance  called  Wharton's  jelly,  and  around  this  the  amnion.  The 
length  of  the  cord  varies:  averaging  from  18  to  20  inches,  it  has  been 
found  60  to  80  inches  in  length,  and  as  short  as  6  or  8  inches.  In  thick- 
ness it  varies  from  the  size  of  the  little  finger  to  that  of  the  thumb  or 
even  larger. 

THE  FCETUS. 
Describe  the  foetus. 

1.  At  the  end  of  the  fourth  week  it  is  a  small  gelatinous  mass,  curved 
upon  itself  and  grayish  in  color.  No  extremities  or  head  can  be  seen, 
and  it  is  so  small  that  it  is  usually  lost  in  the  blood-clots  when  an  abor- 
tion occurs  at  this  time. 

2.  At  the  end  of  the  second  month  it  is  from  1  to  IJ  inches  in  length. 
The  head  is  large,  forming  at  least  one-third  of  the  embryo.  The  eyes 
are  marked  by  two  black  spots  and  the  ears  by  slightly  projectin.ff  rings. 
The  mouth  is  very  large,  but  small  folds  of  skin  have  appeared  about^it 
and  the  eyes,  marking  the  commencement  of  the  lips  and  eyelids.  The 
limbs  are  visible,  with  rudimentary  toes  and  fingers,  and  the  bends  at  the 
elbows  and  knees  are  present.  The  spinal  column  is  divided  into  verte- 
brae, and  the  circulatory  system  is  forming.  The  umbilical  cord  is,  as  a 
rule,  straight  and  inserted  into  the  lower  part  of  the  abdomen.  Centres 
of  ossification  in  some  of  the  bones  have  appeared. 

3.  At  the  end  of  the  third  month.  From  now  on  the  embryo  is  com- 
monly spoken  of  as  the  foetus.  It  is  from  3 J  to  4J  inches  in  length,  and 
weighs  about  1500  or  1600  grains.  The  head  is  still  comparatively  large 
and  the  eyes  prominent,  though  they  and  the  mouth  are  closed.  The 
neck  becomes  evident,  the  fingers  distinctly  separated,  and  the  integu- 
ment thin,  transparent,  and  rose-colored,  though  firmer  than  it  has  been. 
The  genito-urinary  organs  are  developed  and  the  sex  can  be  distinguished. 
The  placenta  now  is  distinctly  formed. 

4.  At  the  end  of  the  fourth  month  the  foetus  measures  6  to  7  inches 
in  length,  and  weighs  between  5  and  6  ounces  avoirdupois.  The  chin, 
which  until  now  has  been  inconspicuous,  becomes  prominent.  The  nails 
appear,  and  soft  white  hairs  are  found  on  the  head.  The  umbilicus  is 
just  above  the  pubes. 


32  PREGNANCY. 

5.  At  the  end  of  the  fifth  month  the  length  of  body  is  8  to  1 0  inches, 
and  the  weight  is  about  9  ounces.  The  skin  is  much  firmer,  and  seba- 
ceous matter  appears  on  its  surface  in  small  areas.  The  small  intestine 
contains  meconium.     The  umbilicus  is  some  distance  above  the  pubes. 

6.  At  the  end  of  the  sixth  month  the  average  length  is  about  12 
inches.  The  weight  now  is  ver}'^  variable,  but  is  in  the  neighborhood  of 
1  pound.  Eyelashes  and  eyebrows  have  begun  to  appear,  and  the  skin 
has  become  darker  and  firmer.  The  testicles  or  ovaries  are  still  in  the 
abdominal  cavity.  According  to  some,  a  child  born  at  this  period  is 
viable. 

7.  At  the  end  of  the  seventh  month  the  foetus  is  from  12  to  15  inches 
long  and  weighs  from  2|  to  4'j  pounds.  The  eyelids,  which  have  been 
closed  since  the  fourth  month,  now  open.  The  skin  is  firmer  and  lighter 
in  color  than  at  the  end  of  the  preceding  month,  and  is  covered  with 
sebaceous  matter.  The  testicles  have  descended  to  the  inguinal  ring, 
and  may  have  entered  the  canal.  This  is  probably  the  earliest  period 
at  which  the  child  can  be  born  with  a  reasonable  chance  of  surviving. 

8.  At  the  end  of  the  eighth  month  the  foetus  is  from  ]  5  to  1 8  inches 
long  and  weighs  from  4|  to  5^  pounds.  The  nails  have  reached  the 
finger-tips  and  the  testicles  are  in  the  scrotum. 

9.  At  the  ninth  month,  or  full  term,  the  foetus  weighs,  on  an  average, 
6j  to  7  pounds,  and  measures  from  18  to  22  inches  in  length.  The  cellu- 
lar tissue  is  tilled  with  fat,  giving  the  child  a  roundness  and  plumpness 
which  is  not  observed  before  term.  The  hair  is  fairly  abundant  and  long, 
and  the  skin  is  quite  firm,  and  paler  even  than  at  the  eighth  month. 

What  is  the  "  vernix  caseosa  "  ? 

It  is  a  greasy,  sebaceous  deposit  covering  the  entire  foetus,  and  making 
its  appearance  first  about  the  sixth  month.  It  consists  of  matter  secreted 
by  the  cutaneous  glands  mixed  with  dead  epithelium.  It  is  alwa3^s  more 
abundant  in  the  axillae  and  groins,  and  is  said  to  be  of  service  as  a  lubri- 
cant during  labor. 

THE   FCETAL.   HEAD. 

Give  a  description  of  the  foetal  head  at  full  term. 

The  head  at  full  term  is  the  hardest  and  largest  part  of  the  foetus,  is 
oval  or  egg-shaped,  and  is  divided  into  two  parts,  face  and  cranium. 
The  face  is  composed  of  fourteen  bones,  two  being  single  and  six  double. 

The  cranium,  the  most  important  part  of  the  foetus  from  an  obstet- 
rical point  of  view,  is  composed  of  eight  bones — a  frontal,  occii)ital,  eth- 
moid and  sphenoid,  two  parietal,  and  two  temporal.  In  the  adult  these 
bones  are  firmly  united,  wliilu  in  the  foetus  they  are  only  so  at  the  base 
of  the  skull,  being  separated  at  the  vc^rtex  or  vault  by  membranous 
intervals,  allowing  of  considerable  overlapping  during  labor  (Fig.  9). 
There  are  five  sutures:  (1)  the  coronal,  which  separates  the  frontal 
from  the  two  parietal  bones ;  (2)  the  sagittal,  or  great  suture,  running 
i'rom  the  root  of  the  nose  backward  to  the  lambdoid  suture :  this  sep- 


THE    FGETAL    HEAD. 


33 


Fig.  9. 


arates  the  two  parietal  bones  and  crosses  the  coronal  suture;  (3)  the 
lambdoid  (Greek  lambda,  A),  which  separates 
the  occipital  from  the  parietal  bones  :  its  apex 
is  at  the  posterior  extremity  of  the  sagittal ; 
(4)  and  (5)  the  temporal  or  squamous  sutures, 
whose  names  indicate  their  positions,  are  un- 
important, as  they  cannot  be  reached  during 
labor. 

Besides  the  sutures  are  two  Ibntanelles,  an 
anterior  and  posterior.  The  anterior  fonta- 
nelle,  or  bregma,  is  the  larger  of  the  two. 
It  is  diamond-shaped,  formed  by  the  crossing 
of  the  coronal  and  sagittal  sutures,  and  has 
four  borders  and  four  angles.  Its  bounda- 
ries are  the  frontal  bone  anteriorly  and  the 
two  parietals  posteriorly.  The  posterior  or 
smaller  fontanelle  is  formed  by  the  junction 
of  the  sagittal  and  lambdoid  sutures.     It  is 

triangular  in  shape,  and  ossifies  rapidly  after  birth.     Its  boundaries  are 
anteriorly  the  two  parietal  bones,  and  posteriorly  the  occipital. 

What  are  the  diameters  of  the  foetal  skull  ? 


Showing  Fontanelles  and  Su- 
tures at  Crown  of  Head; 
A,Ii,  biparietal  diameter. 


1.  The  longitudinal  diameters  are- 
FiG.  10. 


occipito-mental,  5.4  inches,  from 
the  occipital  protuberance  to 
the  chin;  occipito-frontal,  4.6 
inches,  from  the  occipital  pro- 
tuberance to  the  root  of  nose ; 
suboccipito  -  bregmatic,  3.8 
inches,  from  midway  between 
the  occipital  protuberance  and 
foramen  magnum  to  the  centre 
of  the  anterior  fontanelle. 

2.  The  vertical  diameters  are 
— the  mento-bregmatic,  4.4 
inches,  from  the  chin  to  the 
centre  of  the  anterior  fonta- 
nelle ;  the  trachelo-bregmatic, 
3.8  inches,  from  the  bregma 
to  the  anterior  part  of  the  for- 
amen magnum. 

3.  The  transverse  diameters 
are — the  biparietal,  3.8  inches, 
from    one   parietal    tuberosity 

to  the  other;  the  bitemporal,  3.2  inches,  from  the  root  of  one  zygoma 
to  the  corresponding  point  on  the  opposite  side ;  the  bimastoid,  3  inches, 
from  one  mastoid  process  to  the  other.  (These  figures  are  taken  from 
Charpentier,  vol.  i.  pp.  232,  233.) 

3— Obs. 


1-2,  occipito-frontal;  3-4,  occipito-mental;  5-6, 
trachelo-bregmatic;  7-8,  frouto-mental. 


34  PREGNANCY. 

NUTRITION  OF   THE  FCE3TUS. 

How  does  the  child  receive  its  nutrition  in  utero  ? 

Before  the  formation  of  the  allantois  and  umbilical  vesicle  the  ovum 
derives  its  nourishment  from  the  cells  that  form  the  discus  proligerus ; 
then  by  the  albuminous  material  covering  it.  After  reaching  the  uterus 
the  allantois  and  umbilical  vesicle  supply  it  with  nourishment  until  the 
placenta  is  formed. 

As  soon  as  the  placenta  is  formed  the  foetal  nutrition  is  fully  estab- 
lished, as  it  acts  as  an  organ  of  absorption  by  which  nutritious  material 
is  carried  from  the  blood  of  the  mother  to  the  foetus.  This  is  proven 
by  the  fact  that  when  the  placental  circulation  is  interfered  with  to  any 
great  extent  the  foetus  dies. 

How  is  respiration  carried  on  in  utero  ? 

Before  the  placenta  is  formed  it  is  possible  that  there  is  no  respi- 
ration, and  if  there  is,  the  mode  in  which  it  is  carried  on  is  unknown. 

After  the  formation  of  the  placenta  by  the  contact  of  its  vessels  with 
those  of  the  mother,  an  interchange  of  gases  takes  place,  by  which  the 
carbonic  acid  of  the  foetus  is  given  up  and  oxygen  is  absorbed. 

What  secretions  are  carried  on  in  the  uterus  ? 

The  skin  and  sebaceous  glands  secrete  the  vernix  easeosa,  the  liver 
secretes  bile,  the  intestines  secrete  mucus,  and  the  kidneys  urine. 

Describe  the  foetal  circulation. 

To  thoroughly  understand  the  foetal  circulation  the  student  must  bear 
in  mind  the  fact  that  the  vascular  system  differs  materially  from  that  in 
the  adult  in  several  respects.  The  chief  differences  in  the  heart  are  the 
direct  communication  between  the  right  and  left  auricle  and  the  large 
size  of  the  Eustachian  valve.  The  auricles  are  connected  by  a  small 
oval  opening  covered  by  a  fold  which  acts  as  a  valve,  allowing  the  blood 
to  pass  only  from  the  right  to  the  left  auricle.  This  opening  is  called 
the  "foramen  ovale."  The  Eustachian  valve,  passing  from  the  inferior 
vena  cava  on  to  the  wall  of  the  right  auricle,  directs  the  blood  through 
the  foramen  ovale  into  the  left  auricle. 

The  peculiarities  in  the  arterial  system  are  the  communication  be- 
tween the  pulmonary  artery  and  descending  part  of  the  arch  of  the 
aorta  by  a  tube  half  an  inch  in  length,  called  the  "ductus  arteriosus," 
and  the  presence  of  the  hypogastric  or  umbilical  arteries,  which  arise 
from  the  internal  iliacs,  ascend  along  the  sides  ol'  the  bladder,  and,  pass- 
ing out  of  the  abdomen  at  the  umbilicus,  are  continued  along  the  cord 
to  the  placenta. 

The  venous  system  has  a  communication  between  the  placenta  and 
portal  vein  through  the  umbilical  vein,  and  with  the  inferior  vena  cava 
by  the  "ductus  venosus."  The  vessels  in  tlu;  j)lac('nta  lie  in  close  con- 
tact with  the  maternal  vessels,  the  walls  of  Ixithhere  being  very  thin. 
Oxygen  passes  from  the  arteries  of  the  mother  into  the  veins  of  the 


NUTRTTIOX    OF    THE    FGETUS.  35 

placenta,  and  CO2  is  given  up  bj^  the  latter  to  the  former.  Thus  the 
oxygenated  blood  passes  along  the  cord  in  the  umbilical  vein  through 
the  umbilicus  and  to  the  under  surface  of  the  liver.  Part  here  is  dis- 
tributed to  this  organ,  and  part  passes  through  the  ductus  venosus  to 
the  inferior  vena  cava.  Thus  some  of  the  blood  enters  the  inferior  vena 
cava  directly  by  the  ductus  venosus,  but  the  greater  part  passes  through 
the  liver  to  enter  that  vessel  by  the  hepatic  veins.  It  is  thus  that  the 
liver  is  unusually  large  at  an  early  period  of  foetal  life.  The  blood  from 
the  lower  extremities  also  enters  the  inferior  vena  cava,  and  this  mixed 
blood  passes  into  the  right  auricle,  where  most  of  it,  guided  by  the 
Eustachian  valve,  is  directed  through  the  foramen  ovale  into  the  left 
auricle.  From  this  it  enters  the  left  ventricle,  and  from  the  left  ven- 
tricle into  the  aorta,  by  which  it  is  distributed  mainly  to  the  head  and 
upper  extremities,  a  very  small  quantity  entering  the  descending  aorta. 
From  the  head  and  upper  extremities  the  blood  is  returned  through  the 
superior  vena  cava  to  the  right  auricle :  from  this  it  passes  into  the 
right  ventricle,  and  from  the  right  ventricle  through  the  pulmonary 
artery  into  the  ductus  arteriosus,  and  through  this  into  the  descending 
aorta.  A  small  portion  of  this  impure  blood  goes  to  the  lower  extrem- 
ities, but  the  greater  amount  passes  into  the  umbilical  arteries  to  be  car- 
ried to  the  placenta. 

What  changes  occur  in  the  foetal  circulation  at  birth? 

As  soon  as  the  child  is  born  it  cries.  This  inflates  the  lungs,  and  con- 
sequently dilates  the  pulmonary  arteries.  The  blood  now  passes  in  large 
quantities  from  the  right  ventricle  into  the  pulmonary  artery,  and  thence 
through  the  lungs,  where  it  becomes  arterialized,  and  is  returned  by  the 
pulmonary  veins  to  the  left  auricle.  The  ductus  arteriosus,  as  soon  as 
the  child  respires,  contracts,  and  becomes  completely  closed  in  from  four, 
to  ten  daj^s,  remaining  as  a  fibrous  cord.  On  account  of  an  adhesion  of 
the  valve  of  the  foramen  ovale  this  opening  closes.  By  the  tenth  day 
after  birth  it  is  usually  closed,  though  in  some  cases  it  remains  pervious, 
giving  rise  to  a  cyanotic  condition  of  the  child.  The  umbilical  arteries 
between  the  fundus  of  the  bladder  and  the  umbilicalis  become  oblite- 
rated, and  remain  as  fibrous  cords.  The  vein  and  ductus  venosus  are 
completely  obliterated  a  few  days  after  birth,  the  former  becoming  one 
of  the  ligaments  of  the  liver. 

What  is  the  attitude  of  the  full-term  child  in  utero  ? 

The  body  is  arched  forward,  head  flexed  upon  the  chest,  arms  pressed 
tightly  against  the  sides  of  the  chest,  with  the  forearms  flexed  and 
crossed  in  front.  The  thighs  are  flexed  on  the  pelvis  and  the  legs  on 
the  thighs.  The  feet  are  turned  in,  inverted,  and  crossed.  In  the  vast 
majority  of  cases  the  upper  extremity,  or  head,  lies  in  the  lower  segment 
of  the  uterus,  while  the  lower  extremity,  or  breech,  lies  in  the  fundus. 
Motility  or  motion  of  the  foetus  begins  as  early  as  the  tenth  or  twelfth 
week,  but  the  mother  is  not  conscious  of  the  early  movements. 


36  PREGNANCY. 

PHENOMENA  OF  PREGNANCY. 

What  changes  occur  during  gestation  in  the  pelvis? 

No  changes  occur  in  the  bones  of  the  pelvis,  but  marked  aherations 
in  the  articulations  take  place  as  gestation  advances.  The  interarticular 
fibro-cartilages  imbibe  a  serous  fluid,  which  softens  and  relaxes  them,  so 
that  they  allow  of  some  slight  separation  during  the  passage  of  the 
foetus  through  the  pelvis.     This  is  more  marked  in  the  pubic  joints. 

What  changes  occur  during  gestation  in  the  vulva? 

As  the  end  of  pregnancy  approaches  the  labia  majora  become  oedem- 
atous  and  pigmented,  and  may  contain  varices.  The  nymphas  become 
moist,  more  freely  lubricated,  and  hyperaemic.  The  whole  mucous 
membrane  of  the  vulva  acquires  a  dark-red  color. 

What  changes  occur  during  gestation  in  the  vagina? 

It  is  growing  larger  for  the  passage  of  the  head.  It  begins  to  lengthen 
between  the  third  and  fourth  month  on  account  of  the  rising  of  the 
uterus,  but  becomes  shorter  when  the  organ  descends  and  the  foetus 
"engages."  It  acquires  a  violet  color  and  its  secretions  increase.  A 
purely  vaginal  leucorrhoea  may  occur  during  the  first  few  months  of 
pregnancy.     This  is  perfectly  physiological. 

What  changes  occur  during  gestation  in  the  uterus? 

1.  Changes  in  Volume. — As  soon  as  the  ovum  reaches  the  uterus  that 
organ  begins  to  grow.  During  the  first  half  of  pregnancy  it  is  in  active 
growth,  but  later  it  becomes  more  a  distension,  due  to  the  pressure  of 
the  developing  foetus.  According  to  Cazeaux,  the  uterus  at  the  ninth 
inonth  of  pregnancy  measures  13.6  inches  in  its  vertical  diameter,  9.36 
inches  in  its  transverse,  and  8.9  inches  in  its  antero-posterior  diameter, 
and  weighs  nearly  30  ounces.  The  increase  in  volume  is  always  at  the 
expense  of  the  fundus  and  body,  as  the  cervix  is  not  affected  at  all. 
^  2.  Chauf/es  in  Form. — The  form  varies  with  the  presentation,  posi- 
tion, and  the  number  of  children.  If  a  vertex  or  breech,  it  changes 
from  a  triangular  shape  to  that  of  a  flattened  spheroid  from  the  fif'th  to 
tlie  sixth  month,  and  from  the  sixth  to  the  ninth  month  it  becomes 
ovoidal  or  egg-shaped,  with  the  smaller  end  down.  The  position  of  the 
fundus  at  the  different  months  varies  somewhat,  but  averages  about  as 
given  below:  At  the  third  month  the  fundus  can  just  be  appreciated 
above  the  pubes ;  at  the  fourth  month  the  fundus  is  about  2]  finger- 
breadths  above  the  symphysis;  at  the  fifth  month  the  fundus  is  slightly 
more  than  midway  between  the  symphysis  and  umbilicus ;  at  the  sixth 
month  the  fundus  is  even  with  the  umbilicus ;  at  the  seventh  month  it 
is  nearly  3  finger-breadths  above  the  umbilicus;  at  the  eighth  month 
it  is  nearly  to  the  ensiform  a])))en(lix;  aljout  the  middle  of  the  ninth 
month  it  has  reached  the  ensiform  appendix,  and  a  week  or  ten  days 


PHENOMENA   OF   PREGNANCY.  37 

before  labor  begins  it  sinks  somewhat  into  the  pelvic  cavity.     This  is 
called  "the  falling  of  the  uterus." 

3.  Changes  in  Consistency. — Instead  of  being  hard  and  fibrous,  as  in 
virgins,  it  gradually  becomes  soft  and  elastic,  so  that  it  moulds  itself 
about  the  foetus,  and  through  its  walls  can  readily  be  felt  the  different 
portions  of  the  child. 

4.  Changes  in  Direction. — The  uterus  changes  its  direction  continually 
according  to  the  position  taken  by  the  woman,  until  it  has  risen  well  out 
of  the  pelvis,  when  its  tendency  is  to  lie  forward  on  the  abdominal  wall. 
This  is  in  reality  an  anteversion.  There  is  also  a  so-called  ' '  lateral  ob- 
hquity  "  of  the  uterus.  The  cause  of  this  is  unknown,  but  in  most  cases 
it  bends  to  the  right  side. 

5.  Changes  in  its  Relations  to  the  Surrounding  Organs. — ^While  in 
the  virgin  the  uterus  lies  between  and  in  relation  with  the  bladder  (ante- 
riorly) and  rectum  (posteriorly),  at  full  term  nearly  the  entire  organ  lies 
against  the  anterior  abdominal  wall,  only  a  very  small  portion  touching 
the  posterior  surface  of  the  bladder.  Posteriorly  it  is  in  relation  with 
the  rectum  and  the  iliac  vessels. 

6.  Changes  in  Structure. — We  find  in  the  peritoneal  coat  a  simple 
hypertrophy  and  a  distension  as  the  uterus  increases  in  size.  This  coat 
does  not  become  thinned  out.  In  the  muscular  layer  marked  alterations 
take  place.  The  previously  small  fibres  become  greatly  increased  in  size 
in  all  directions,  but  especially  so  in  length.  There  is  also  a  development 
of  new  unstriped  muscular  fibres  and  of  connective  tissue.* 

7.  The  Power  of  Contraction. — Painless,,  intermittent  contractions 
constantly  occur  after  the  third  month.  They  aid  in  keeping  the  foetus 
in  position  and  help  to  keep  the  blood  in  circulation. 

8.  Changes  in  the  Uterine  Vessels. — As  the  organ  increases  in  size  the 
arteries  and  veins  grow  very  large ;  at  the  same  time  new  vessels  are 
formed. 

9.  The  changes  in  the  mucous  membrane  and  formation  of  the  decidua 
were  given  on  page  27. 

What  changes  occur  during  gestation  in  the  cervix? 

The  first  change  which  occurs  in  the  cervix  is  a  softening,  beginning 
at  the  OS  externum  and  gradually  passing  upward,  until  by  the  eighth 
month  the  entire  cervix  is  soft  and  ready  to  dilate,  allowing  the  present- 
ing part  of  the  child  to  descend  and  rest  upon  the  external  os.  Toward 
the  end  of  pregnancy  the  os  externum  usually,  though  not  always,  be- 
comes patulous,  and  will  admit  the  tip  of  the  examining  finger.  In 
multiparee  (women  who  have  borne  children)  this  is  always  the  case ; 
while  the  cervix  is  invariably  more  or  less  torn  during  the  birth  of  the 
first  child,  previous  to  which  event  such  patulency  is  rare. 

■'•■  For  a  more  complete  description  of  the  muscular  fibres  of  the  uterus 
during  gestation  the  student  is  referred  to  the  Cydopsedia  of  Obstetrics  and 
Gynecology,  by  Charpentier,  vol.  i.  p.  136. 


38  PREGNANCY. 

What  changes  occur  during  gestation  in  the  ovaries,  tubes,  and 
ligaments  ? 

The  ovaries  and  tubes  rise  in  the  abdominal  cavity  and  become  hyper- 
trophied.  Ovulation  ceases.  The  broad  and  round  ligaments  increase 
in  size  and  rise  with  the  growtli  of  the  uterus. 

What  changes  occur  during  gestation  in  the  mammary  glands? 

Soon  after  impregnation  has  occurred  the  breasts  begin  to  enlarge  and 
the  veins  become  more  prominent.  The  areola  in  brunettes  assumes  a 
dark-brown  color,  in  blonds  only  moderately  so,  and  a  few  small  tubercles 
appear  in  the  areola.  These  are  called  the  "  tubercles  of  Montgomery." 
Around  the  primary  or  true  areola  small  dark  spots  are  seen  w^hieh  con- 
stitute the  so-called  secondary  areola.  Toward  the  end  of  pregnancy  a 
few  drops  of  a  serous  fluid  can  be  squeezed  from  the  nipple  :  this  is  the 
colostrum. 

What  changes  occur  during  gestation  in  the  cutaneous  system? 

Here  we  find  pigmentation  occurring  in  blotches  over  different  parts 
of  the  body,  and  frequently  on  the  face.  These  usually,  but  not  always, 
disappear.  The  labia  majora  become  very  dark  in  most  cases,  and  run- 
ning ui)  the  abdomen  in  the  median  line  from  the  pubes  to  the  umbilicus 
is  a  brown  line.  As  a  rule,  the  pigment  is  deposited  around  the  umbili- 
cus, and  then  the  line  extends  on  up  the  abdomen  to  the  ensiform  ap- 
pendix. In  the  iliac  regions  reddish-purple  striae  are  seen.  These  are 
ecchymoses  caused  by  tearing  apart  the  small  muscular  fibres  from  the 
rapid  distension  of  the  abdominal  wall.  After  labor  they  acquire  a 
white  color,  and  always  remain  in  the  abdominal  wall  as  cicatricial  or 
scar  tissue. 

What  changes  occur  during  gestation  in  the  blood? 

There  is  an  increase  in  the  quantity  of  water  and  fibrin,  and  a  decrease 
in  the  amount  of  albumin,  iron,  and  excrement  it  ious  substances.  There 
is  also  a  decrease  in  the  number  of  red  corpuscles.  These  changes  are 
more  marked  aftei  tae  sixth  month.  The  heart  becomes  hypertrophied, 
because  there  is  more  force  needed.  The  hypertroj^hy  is  entirely  in  the 
left  ventricle.  Its  weight  is  increased  from  one-fifth  to  one-fourth. 
After  childbirth  the  heart  undergoes  a  retrograde  action  and  regains  its 
normal  size.  There  is  an  increased  tension  in  the  arteries  and  an  en- 
largement of  the  superficial  blood-vessels,  especially  of  the  thighs. 

What  changes  occur  during  gestation  in  the  respiratory  appa- 
ratus ? 

During  pregnancy  the  chest  becomes  broader,  the  antero-posterior  and 
vertical  diameters  are  diminished,  and  there  is  a  tendency  to  dyspnoea  on 
the  slightest  exertion. 


SIGNS,    SYMPTOMS,    AND    DIAGNOSIS  OF    PREGNANCY.       39 

What  changes  occur  during  gestation  in  the  digestive  appa- 
ratus ? 

The  digestive  organs  are  alwaj^s  crowded  out  of  their  normal  position. 
Pressure  on  the  rectum  causes  constipation,  and  hemorrhoids  may  result. 
The  crowding  upward  of  the  stomach  may  cause  vomiting. 

What  changes  occur  during  gestation  in  the  urinary  organs  ? 

There  are  compression  and  displacement  of  the  bladder,  causing  an 
irritability,  so  that  after  the  sixth  or  seventh  month  a  pregnant  woman 
is  only  able  to  retain  her  urine  for  a  very  short  time.  A  cystitis  may 
also  be  set  up.  The  urethra  is  usually  displaced,  and  the  kidneys  are 
pressed  upon,  sometimes  enough  to  cause  a  congestion  which  at  times 
results  in  an  albummuria.  The  urine  also  shows  marked  changes,  there 
being  an  increase  in  the  water,  the  chlorides,  and  carbonates,  and  a  de- 
crease in  the  phosphates,  sulphates,  urea,  and  uric  acid.  "Kiestein" 
is  almost  always  found  in  the  urine  of  a  pregnant  woman.  This  is  a 
dejwsit  seen  when  the  urine  has  stood  for  some  time,  and  it  is  not  always 
a  sure  sign  of  pregnancy,  as  has  been  supposed. 

What  changes  occur  during  gestation  in  the  osseous  system  ? 

Changes  have  been  noted.  These  consist  in  deposits  of  bone  between 
the_  internal  table  of  the  cranial  bones  and  the  dura  mater.  These  de- 
posits are  called  osteophytes. 

What  changes  occur  during  gestation  in  the  nervous  system  ? 

Some  changes  almost  invariably  occur.  Neuralgic  pains  over  different 
parts  of  the  body,  toothache,  and  perverted  sense  of  taste  or  smell  are 
frequently  observed. 

SIGNS,  SYMPTOMS,  AND  DIAGNOSIS  OF  PREGNANCY. 

Name  the  symptoms  of  pregnancy  as  nearly  as  possible  in  the 
order  in  which  they  occur,  including  a  few  points  in  dia- 
gnosis. 

1st.  Suppression  of  the  Menses. — If  a  woman  in  perfect  health,  who 
has  been  menstruating  regularly,  suddenly  ceases  to  do  so,  with  no  dis- 
turbances from  it,  she  is  in  all  probability  pregnant.  There  are  many 
causes  for  amenorrhoea,  but  as  a  rule  disagreeable  symptoms  accompany 
this  malady.  On  the  other  hand,  women  occasionally  menstruate  regu- 
larly for  several  months  after  impregnation  has  taken  place,  and  cases 
have  been  reported  where  this  function  was  carried  on  throughout  ges- 
tation. Then,  again,  pregnancy  has  occurred  when  the  function  was 
absent,  as  during  lactation. 

2d.  Sympathetic  Nervous  Disturhances. — Some  sympathetic  disturb- 
ances constantly  occur  in  most  pregnant  women.  These  are  apt  to  be 
more  marked  in  highlj'  neurotic  patients  or  those  of  a  nervous  temper- 
ament.    Among  them  are  found  itching,  tingling,  or  ' '  peculiar  sensa- 


40  PREGNANCY. 

tions"  in  the  breasts,  and  neuralgic  pains  over  various  parts  of  the 
body,  most  frequentl}^  in  the  face.  There  maj'  be  toothache,  witli  no 
destructive  changes  in  the  teeth,  and  often  the  woman  who  naturally  is 
of  a  very  amiable  disposition  becomes  sensitive,  morose,  irritable,  or 
despondent.  Occasionally  a  marked  tendency  to  frequent  attacks  of 
syncope  is  developed,  but  most  marked  of  all  are  the  digestive  disturb- 
ances. There  may  be  a  capricious  appetite,  with  longings  for  the  most 
peculiar  articles  as  food,  such  as  slate-pencils,  plaster,  chalk,  charcoal, 
etc. 

But  of  greater  frequency  are  the  nausea  and  vomiting.  This  occurs 
usually  on  rising  in  the  morning;  hence  it  has  been  called  "morning 
sickness. ' '  It  may  be  seen  soon  after  impregnation  has  occurred,  but 
as  a  rule  not  until  the  middle  or  end  of  the  second  month.  The  cause 
of  this  morning  sickness  has  been  disputed,  but  the  generally  received 
oi^inion  now  is  that  it  is  purely  a  reflex  disturbance,  due  to  the  irritation 
of  the  uterine  nerves  by  the  pressure  of  the  growing  muscular  fibres 
upon  them. 

3d.  Glandular  Changes. — Those  occurring  in  the  breast  and  kidney 
have  already  been  described  (pp.  38  and  39).  There  is  one  more  which 
deserves  mention  :  this  is  the  activity  of  the  salivary  glands.  Occasion- 
ally very  severe  and  annoying  ptyalism  is  seen.  This  usually  ceases 
spontaneously  early  in  pregnancy. 

4th.  Other  digestive  disturbances,  as  flatulency,  heartburn,  consti- 
pation, or  sometimes  diarrhoea,  may  occur. 

5th.  Rrfi<i.c  Pigmentary  Changes. — These  have  already  been  described 
(on  p.  38).  They  are  very  constant  in  brunettes,  less  marked  in  blonds, 
and  may  be  entirely  absent  in  women  with  red  hair. 

6th.  A  violet  color  of  the  vaginal  mucous  membrane  is  seen  fre- 
quently. This  is  a  capillary  congestion  caused  by  the  pressure  of  the 
gravid  uterus,  and  is  of  very  little  value,  as  any  pelvic  tumor  may  cause 
the  same  condition. 

7th.  A  marked  irritability  of  the  bladder  may  be  found.  At  times 
this  becomes  very  annoying,  and  increases  as  pregnancy  advances. 

8th.  Cha,n(fes  in  the  Umbilicus. — At  first  the  umbilicus  is  somewhat 
depressed.  It  then  becomes  even  with  the  abdominal  wall,  later  bulges 
slightly,  and  during  the  latter  months  may  be  drawn  upward. 

9th.  Ab(](jniinal  enlargment  is  first  noticed  about  the  fourth  month, 
when  the  uterus  has  risen  well  out  of  tlie  pelvis.  From  this  time  on  it 
increases  rapidly,  until  the  ninth  month,  when  it  has  reached  the 
diaphragm.     This  is  much  more  marked  in  short  women. 

loth.  Intermittent  Uterine  Contractions. — This  is  a  constant  symp- 
tom after  the  uterus  is  large  enough  to  be  felt,  and  when  found  by 
a  competent  observer  is  a  very  valuable  sign.  It  consists  in  regular 
intermittent  contractions  of  tlic,  uterus,  occurring  every  five,  ten,  or 
fifteen  minutes.  They  are  painless,  and  therefore  not  appreciated  by 
the  mother. 


SIGNS,    SYMPTOMS,    AND    DIAGNOSIS  OF    PREGNANCY.       41 

11th.  '''' Quickening.'''' — This  is  a  sensation  felt  by  the  mother  when 
the  uterus  has  reached  a  sufficient  height  in  the  abdominal  cavity,  so 
that  the  movements  of  the  foetus  may  be  felt  against  the  abdominal 
wall.  It  usually  occurs  first  about  the  eighteenth  or  nineteenth  week, 
and  is  described  as  a  slight  fluttering.  The  movements  become  stronger 
and  more  frequent  as  pregnancy  advances,  and  may  often  be  seen  as  a 
quick  bulging  of  the  abdominal  wall.  This  is  not  a  very  valuable  sign, 
as  women  who  think  themselves  pregnant  often  imagine  that  they  feel 
the  foetal  movements.  A  similar  sensation  to  ''quickening"  may  be 
caused  by  spasmodic  contractions  of  the  abdominal  muscles  or  flatus  in 
the  intestines. 

12th.  Changes  in  the  Cervix. — As  early  as  the  third  month  it  may  be 
noticed  that  the  cervix  is  more  easilj^  felt  on  vaginal  examination.  It 
soon  becomes  softer,  and  in  primiparae  somewhat  different  in  shape  and 
longer  than  in  multiparse.  In  the  latter  it  has  more  of  an  oval  shape, 
slightly  flattened  antero-posteriorly,  while  in  the  former  it  is  long  and 
conical.  The  os  externum  until  the  latter  months  of  pregnancy,  and 
sometimes  until  labor  begins,  is  tightly  closed  in  primiparse,  while  in 
multiparae,  on  the  contrary,  it  will  usually  admit  the  tip  of  the  finger  by 
the  third  or  fourth  month. 

13th.  Ballottement. — This  is  the  sensation  which  is  felt  when,  with 
two  fingers  in  the  anterior  cul-de-sac  of  the  vagina,  the  foetus  is  suddenly 
pushed  away,  floats  in  the  liquor  amnii,  and  falls  back  again,  striking  the 
fingers.  It  is  an  exceedingly  valuable  sign  of  pregnancy  when  founds  as 
no  other  condition  will  give  it.  However,  it  requires  considerable  expe- 
rience for  one  to  be  positive  about  this  sign.  It  can  usually  be  appre- 
ciated between  the  fourth  and  seventh  months.  After  this  the  foetus 
has  become  so  large  and  fits  so  tightly  in  the  lower  segment  of  the  ute- 
rus that  it  is  impossible  to  get  ballottement.  In  order  to  make  ballotte- 
ment easy  the  woman  should  lie  with  her  shoulders  well  elevated,  or, 
better  still,  sit  or  stand.  There  is  also  a  so-called  abdominal  ballotte- 
ment. This  is  appreciated  by  placing  one  hand  on  each  side  of  the  ab- 
dominal wall,  and  pushing  the  foetus  with  a  quick  movement  of  one  of 
the  hands.     It  is  felt  to  strike  the  other. 

In  breech  cases  a  form  called  "cephalic  ballottement"  is  obtained. 
This  is  gotten  by  placing  one  hand  over  the  head  and  pushing  it  away. 
It  rebounds  and  strikes  the  hand,  giving  an  impulse  as  in  the  other 
forms. 

14th.  Auscidkition. — This  is  always  to  be  practised  with  the  woman 
lying- on  her  back  :  the  stethoscope  should  be  used,  and  applied  directly 
to  the  abdominal  wall.  Over  the  abdomen  of  a  pregnant  woman  we 
may  hear  three  sounds.  These  are  the  foetal  heart,  the  uterine  souffle, 
and  the  funic  souffle. 

(1)  The  Foetal  Heart. — This  is  the  one  positive  sign  of  pregnancy, 
and  can  usually  be  heard  by  the  beginning  of  the  fifth  month,  though 
occasionally  earlier.  It  is  very  variable  both  in  rapidity  and  strength. 
The  frequency  ranges  from  110  or  120  to  160  or  170,  and  the  strength 


42  PREGNANCY. 

varies  according  to  the  sex  and  size  of  the  child.  In  males  and  large 
children  it  is  slower  and  stronger ;  in  small  children  and  females  it  is 
more  rapid  and  weaker.  As  a  rule,  male  children  are  somewhat  larger 
and  heavier,  hence  the  foetal  heart-sound  is  slower  and  stronger.  It  may 
sometimes  be  heard  over  the  entire  abdomen,  though  there  is  always  a 
point  or  area  of  maximum  intensity.  This  will  be  further  considered 
when  the  subjects  of  presentation  and  position  are  taken  up. 

(2)  The  Uterine  Souffle. — This  is  a  peculiar  soft  blowing  or  harsh 
whizzing  sound,  synchronous  with  the  maternal  pulse  and  heard  at  some 
point  over  the  abdominal  wall.  It  was  formerly  supposed  to  be  a  sound 
caused  by  the  passage  of  blood  through  the  placenta,  and  hence  has 
been  also  called  the  "  placental  bruit."  It  may  be  heard  after  the  fifth 
month,  and  varies  considerably  in  intensity  and  position,  sometimes 
being  absent,  then  suddenly  appearing  over  one  point  of  the  abdomen, 
to  be  heard  a  few  minutes  later  at  a  point  very  remote  from  this.  It  is 
probably  caused  in  some  unexplained  way  by  the  blood  passing  through 
the  tortuous  uterine  arteries.  That  it  is  not  placental  in  origin  is  con- 
clusively proven  by  the  fact  that  it  is  heard  after  the  placenta  has  been 
expressed,  and  in  cases  of  uterine  enlargment  from  tumors  where  the 
condition  of  pregnancy  is  absent.  Thus  it  is  apparent  that  this  sign  is 
of  little  value  in  diagnosing  pregnane}'. 

(oj  Tlie  Funic  Souffle. — The  funic  or  umbilical  souffle  is  a  soft  blow- 
ing murmur,  synchronous  with  the  foetal  heart-sounds,  and  when  heard 
may  be  situated  at  any  point  over  the  abdomen.  It  is  very  rarely  found, 
but  when  so  is  probably  created  by  a  tension  of  the  cord  or  pressure  of 
the  same  against  the  uterine  wall  by  some  bony  prominence  of  the  child. 
The  tension  would  be  most  Irequently  caused  by  a  cord  wound  around 
the  neck  or  perhaps  a  knotted  cord. 

15th.  Palpation. — By  abdominal  palpation  we  appreciate  different 
parts  of  the  child  and  recognize  the  position  and  presentation.  It  is  of 
little  value  before  the  sixth  month.  On  this  subject  more  will  be  said 
later. 

Many  of  the  preceding  signs  and  symptoms  of  pregnancy  occur  at  or 
about  the  same  time,  so  that  it  is  almost  impossible  to  give  them  in  ex- 
actly the  order  in  which  they  occur.  However,  an  attemiit  has  been 
made  to  describe  them  as  nearly  as  possible  in  order  of  their  appearance. 
It  might  be  mentioned  here  that  many  authors  classify  them  according 
to  the  month  they  occur  or  their  relative  importance.  Others  divide 
them  into  subjective  and  objective  symptoms. 

What  are  the  four  most  important  symptoms  or  signs  ? 

The  foetal  heart; 

I^allottement ; 

Milk  or  colostrum  in  the  breasts  of  pregnancy; 

Suppression  of  the  menses. 


DURATION   OF   PREGNANCY.  43 

How  would  you  differentiate  between  the  first  and  subsequent 
pregnancies  ? 

Primiparce.  Multiparce.. 

Nipple  usually  small  and  unde-  Nipples  large,  and  apt  to  be  well 

veloped.  developed. 

Not  likely  to  be  any  striae  on  the  Striae    frequently   found   on    the 

breasts.                           ^    ^  breasts. 

Abdomen  tense  and  resisting  to  Abdomen    usually   very  lax   and 

touch.  yielding. 

Striae,  if  present,   are  of  a  pur-  Striae  white,  though   there  may 

plish-red  color.  also  be  some  reddish  ones. 

The  vagina  has  a  markedly  corru-  The  vagina  feels  smooth. 

gated  feel. 

The  cervix  is  longer  and  conical.  Cervix  short,  and  very  likely  some- 
what lacerated. 

Perineum  is  tense  and  long.  Perineum  may  be  torn. 

Fourchette  is  present.  No  fourchette. 

What  methods  of  examination  should  be  pursued  in  making  the 
diagnosis  of  pregnancy  ? 

First,  the  woman  should  be  questioned  concerning  the  date  of  her  last 
menstruation  and  its  character  and  regularity  previous  to  stoppage.  The 
physician  should  question  her  as  to  any  digestive  disturbances,  such  as 
nausea,  vomiting,  etc. ,  from  which  she  may  have  been  suffering ;  then 
as  to  whether  or  not  she  has  had  any  pecuHar  sensations  in  her  breasts. 

Secondly,  the  breasts  and  abdomen  are  to  be  inspected.  This  is  best 
done  with  the  patient  in  a  recumbent  position,  as  afterward  a  vaginal 
examination  must  be  made,  and  this  is  much  better  done  in  the  dorsal 
decubitus.  The  shape  of  the  breast  is  observed,  the  areola,  the  super- 
ficial veins,  and  the  tubercles  of  Montgomery ;  also  the  size  of  the  ab- 
domen, its  shape  and  pigmentation.  Percussion  is  then  performed,  and 
afterward  palpation  and  auscultation. 

Thirdly,  a  vaginal  examination  is  made.  The  secretions  are  noted, 
the  cervix  and  os  felt,  and  the  finger  is  swept  in  all  directions  to  deter- 
mine roughly  the  size  of  the  pelvis. 

DURATION  OF  PREGNANCY. 

What  is  the  average  duration  of  pregnancy  ?  and  how  is  it  com- 
puted ? 

The  average  duration  is  278  days.  This  is  a  little  more  than  nine  cal- 
endar and  a  trifle  less  than  ten  lunar  months.  As  insemination  is  not 
necessarily  conception,  it  is  impossible  to  determine  accurately  the  exact 
day  when  labor  should  occur.  Conception  may  take  place  as  long  as  ten 
days  after  insemination.  For  all  practical  purposes  280  days  is  counted 
from  the  first  day  of  the  last  menstruation.     One  rule  in  common  use  is 


44  PREGNANCY. 

to  add  three  days  to  the  last  day  of  the  last  menstruation,  and  subtract 
three  calendar  months  from  a  year  from  that  date.  If  February  is  in- 
cluded, add  five  instead  of  three  days.  Cases  have  been  reported  where 
the  pregnancy  has  continued  290,  300,  and  even  313  days. 

DIFFERENTIAL  DIAGNOSIS   OF  PREGNANCY. 
What  conditions  resemble  or  may  be  taken  for  pregnancy? 

(1)  Spurious  pregnancy;  (2j  obesity;  (3)  ascites;  (4j  tympanites; 
(5)  subinvolution  of  uterus;  (6)  ovarian  tumors;  (7)  fibroid  tumors; 
(8)  retained  menses. 

What  is  spurious  pregnancy,  and  how  differentiated  from  true? 
This  usually  occurs  about  the  fortieth  year  of  life  or  at  the  menopause, 
but  may  be  met  with  at  any  time  during  the  child-bearing  period.  It  is 
usually  associated  with  ovarian  irritation,  and  is  met  with  most  frequently 
among  the  upper  classes.  It  may  begin  by  some  irregularity  in  the  men- 
strual flow.  Then  the  abdomen  enlarges,  either  from  a  crowding  down 
of  the  abdominal  wall  from  a  deposit  of  fat  or  from  distended  intestines. 
The  muscles  become  very  rigid,  and,  what  makes  the  diagnosis  more  dif- 
ficult, oftentimes  a  condition  of  hypergesthesia  is  found.  The  patient 
complains  of  a  loss  of  appetite  and  of  morning  nausea.  Peculiar  feelings 
in  the  breasts  may  be  described,  and  occasionally  these  glands  become 
enlarged.  This  condition  may  go  on  until  a  spurious  labor  begins,  unless 
a  diagnosis  be  made  and  the  patient  be  assured  she  is  not  pregnant.  If 
care  is  taken  a  diagnosis  of  the  condition  is  easily  made.  On  being 
questioned  it  will  probably  be  found  that  menstruation  has  been  going 
on,  though  perhaps  altered  in  character  and  at  infre<iuent  intervals.  No 
foetal  movements  can  be  felt,  nor  can  a  foetal  heart  be  heard.  On  vaginal 
examination  the  cervix  is  found  long  and  hard  and  the  uterus  not  en- 
larged. If  doubt  still  exists,  by  giving  an  anaesthetic  the  tumor  will 
disappear. 

How  may  pregnancy  be  differentiated  from  obesity? 

In  some  women  tliis  condition  is  associated  with  irregularities  in  the 
menstrual  flow  which  load  them  to  imagine  they  are  pregnant.  The  con- 
dition may  be  so  marked  that  even  though  pregnancy  does  exist  the 
uterus  cannot  be  felt  on  palpation.  The  absence  of  all  signs  and  symp- 
toms of  pregnancy,  especially  of  the  mammary  changes  and  auscultatory 
signs,  makes  the  diagnosis  easy. 

How  may  pregnancy  be  differentiated  from  ascites  ? 

By  making  a  careful  i)liysical  examination  of  the  ))atient  the  condition 
causing  the  ascites  can  usually  1)0  discoverc*!.  Furthermore,  if  the  pa- 
tient be  placed  upon  her  back,  it  will  be  noticed  that  the  abdomen  bulges 
more  at  one  point  than  at  another,  and  marked  fluctuation  can  usually 
be  obtained. 


DEATH   OF    FCETTJS   IN   UTERO.  45 

How  may  pregnancy  be  differentiated  from  tympanites  and  sub- 
involution of  the  uterus  ? 

This  condition  is  easil}"  recognized  by  percussing  the  abdomen. 

Subinvolution  of  the  uterus  can  be  mistaken  for  pregnancy  only  at  a 
very  early  period,  when  a  positive,  diagnosis  is,  under  any  circumstances, 
impossible.  However,  it  is  almost  always  associated  with  symptoms 
referable  to  uterine  troubles,  such  as  pain  in  the  sides  or  back,  a  leucor- 
rhoeal  discharge,  and  tenderness  on  pressure  over  the  uterus.  By  wait- 
ing and  finding  no  increase  in  the  size  of  the  organ  the  diagnosis  is 
assured. 

How  may  pregnancy  be  differentiated  from  ovarian  and  fibroid 
tumors  ? 

When  either  of  these  conditions  exist  alone,  by  a  careful  examination 
the  diagnosis  is  not  difficult ;  but  when  pregnancy  is  complicated  by  one 
or  the  other,  it  is  sometimes  extremely  difficult,  and  occasionally  impos- 
sible, to  arrive  at  a  positive  conclusion.  With  the  former  we  usually 
have  a  continuance  of  menstruation,  may  get  fluctuation,  and  with  the 
absence  of  cervical  changes  and  auscultatory  phenomena  the  diagnosis  is 
made.  In  the  latter  the  peculiar  hard  and  round  feeling  of  the  mass,  a 
profuse  menstruation,  and  absence  of  foetal  heart-sounds  will  materially 
aid  in  making  a  diagnosis.  In  both  cases  the  history  is  of  great  import- 
ance. 

How  may  pregnancy  be  differentiated  from  retained  menstrual 
fluid? 

This  is  most  likely  to  occur  in  girls  who  have  never  menstruated,  and 
when  found  in  such  cases  the  condition  would  be  immediately  suspected, 
and  an  examination  would  reveal  the  presence  of  an  imperforate  hymen 
or  some  other  obstruction  to  the  outlet  for  the  flow.  Or,  if  it  occur  later, 
the  fact  that  no  mammary  changes  were  found,  the  cervix  normal,  aus- 
cultation negative,  and  ballottement  absent  would  prove  the  non-exist- 
ence of  pregnancy.  In  both  cases  a  history  would  probably  be  of  im- 
portance, and  this  would  elicit  the  fact  that  the  patient  had  sufl"ered 
from  excessive  abdominal  pains  during  the  time  when  the  menstrual 
flow  should  have  occurred. 

DEATH  OF   FCETUS    IN  UTERO. 

What  symptoms  would  indicate  the  probable  death  of  the  foetus 
in  utero,  and  how  would  you  diagnose  this  condition? 

The  mother  begins  to  suffer  from  ill  health.  She  becomes  despondent 
with  no  apparent  cause,  and  loses  strength  and  appetite.  Her  abdomen, 
which  has  been  gradually  enlarging,  suddenly  ceases  to  increase  in  size, 
and  the  breasts,  which  were  firm,  become  flabby  and  atrophied,  and  the 
movements  of  the  foetus,  which  have  previously  been  felt,  suddenly  or 


46  PREGNANCY. 

perhaps  gradually  cease.  The  diagnosis  is  made  positive  if  with  t^ie 
Si^iiptoms  recorded  above  we  find  no  foetal  heart-sounds  for  several  suc- 
cessive days,  when  previously  they  have  been  heard. 

HYG-IENE   OF    PREGNANCY. 

What  hygienic  rules  should  be  observed  during  pregnancy? 

The  pregnant  woman  must  be  especially  particular  about  her  clothing. 
Her  garments  should  be  loose-fitting  and  warm.  Corsets  are  to  be  abso- 
lutely forbidden,  as  they  compress  the  breasts  and  by  pressure  on  the 
walls  of  the  chest  cause  an  abdominal  tyj^e  of  respiration,  which  dis- 
places the  stomach,  liver,  and  intestines,  and  gives  rise  to  much  discom- 
fort, and  frequently  to  serious  results.  She  must  have  })lenty  of  fresh 
air  and  take  moderate  exercise,  excluding  all  violent  forms,  such  as 
horseljack  riding,  rapid  walking,  running  up  stairs,  etc.  She  should 
avoid  excitement.  Her  diet  must  be  wholesome  and  nutritious,  and  the 
bowels,  which  are  almost  invariably  constipated,  should  be  kept  open  by 
mild  laxatives,  enemas,  or  mineral  waters.  Intercourse  ought  to  be  only 
moderately  indulged  in,  if  at  all,  during  the  early  months  and  prohibited 
during  the  latter  months.  If  patients  have  been  in  the  habit  of  douch- 
ing tlicmselves  regularly  and  intelligently,  this  practice  may  be  con- 
tinued. Baths  may  be  taken  throughout,  but  should  never  be  too  hot, 
or,  on  the  other  hand,  too  cold. 

DISORDERS   OP  PREGNANCY.     ■ 
How  may  the  disorders  of  pregnancy  be  divided  ? 

(1)  Into  those  due  to  mechanical  causes  (hemorrhoids,  dyspnoea,  vari- 
cose veins,  etc.). 

(2)  Into  those  of  reflex  origin  or  sympathetic  disturbances  (nausea, 
vomiting,  etc.). 

(o)  Into  those  due  to  pathological  conditions  of  the  uterus  or  ovaries 
(retroversion  and  moles). 

(4)  Into  certain  diseases  which  are  engrafted  upon  pregnancy:  among 
these  anfemia  and  albuminuria  are  found. 

Describe  the  disorders  of  digestion. 

The  most  impijrtant  are  nausea  and  vomiting.  These  disorders  usu- 
ally require  no  treatment,  as  they  generally  disai)i)ear  by  the  third  or 
fourth  month.  However,  some  cases  continue,  and  are  of  such  a  severe 
type  that  they  must  be  treated.  The  causes  are  reflex  in  origin,  and  are 
(I)  pressure  on  the  uterine  nerves  from  stretching  of  the  muscidar  fibres 
of  the  uterus;  (2)  irritation  of  the  uterine  nerves  from  a  flexion  of  the 
uterus;  (3)  erosion  on  the  cervix;  (4)  emotion. 

Si/inptorns. — In  the  severe  cases  the  vomiting  occurs  not  only  in  the 
morning,  but  whenever  food  is  taken,  and  even  when  the  stomach  is 


DISORDERS   OF    PREGNANCY.  47 

empty  a  violent  retching  continues,  so  that  the  patient  in  a  short  time 
becomes  exhausted  and  emaciated.  The  pulse  is  rapid  and  feeble,  the 
temperature  elevated,  the  tongue  dry  and  coated,  and  delirium,  followed 
by  death,  may  occur. 

These  grave  cases  are  said  to  be  more  often  associated  with  multiple 
gestations. 

Treatment. — In  the  milder  cases,  where  the  vomiting  occurs  in  the 
morning,  relief  may  often  be  obtained  by  giving  the  patient  a  half  hour 
before  rising  a  glass  of  hot  milk  :  this  while  in  a  recumbent  position.  A 
great  many  remedies  have  been  used,  but  all  are  very  uncertain.  Among 
them  may  be  mentioned  oxalate  of  cerium  in  gr.  ij  to  gr.  xx  doses ;  di- 
lute hydrocyanic  acid  in  ^  doses ;  tincture  of  iodine  in  Titij  doses  ;  wine 
of  ipecac  in  milk  (Tr\,x-'Hlxx) ;  the  bromides  in  effervescence  ;  small  doses 
of  calomel  (gr.  i-J),  frequently  repeated ;  pepsin ;  chloral  hydrate  in 
gr.  j  doses ;  and  hydrochlorate  of  cocaine  in  ^-\  gr.  doses ;  iced  cham- 
pagne ;  and  externally  both  heat  and  cold  applied  over  the  epigastriuip. 
Dilating  the  cervix  has  been  done  with  good  results  in  some  cases.  In 
the  most  severe  cases  the  stomach  must  be  given  complete  rest  and 
rectal  alimentation  resorted  to.  A  good  nutrient  enema  maj^  be  made 
up  of— 

Peptonized  milk,  ^v ; 

Liquid  peptonoids,  ^j ; 

Tr.  opii,  i^x; 

Salt,  q.  s. 

Or,  Beef  tea  (peptonized),  ^iv; 

Brandy,  5ss; 

Laudanum,  "»U,x-xx. 

Sig.  Either  given  every  four  hours,  washing  out  the  rectum  before 
each  enema. 

If  after  a  trial  none  of  these  prove  successful,  and  the  patient's  con- 
dition is  steadil3^  growing  worse,  as  a  last  resort  induce  abortion.  Dilate 
the  cervix  first  and  wait  a  day,  as  this  may  check  the  vomiting.  If  not, 
rupture  the  membrane.  The  methods  will  be  described  farther  on. 
Always  call  a  consultation  before  an  operation  of  this  kind. 

The  other  digestive  disturbances  are  constipation  and  diarrhoea.  The 
former  is  by  far  the  more  frequent,  though  the  latter  is  not  nearly  as 
rare  as  is  generally  supposed.  Constipation  is  caused  mainly  by  im- 
paired peristaltic  movements  of  the  intestines,  which  is  brought  about 
by  pressure  from  the  gravid  uterus.  This  must  be  relieved  by  proper 
diet,  mild  laxatives,  and  enemata. 

Where  diarrhoea  occurs  it  should  be  promptly  treated,  for  when  ex- 
cessive it  has  a  decided  tendency  to  produce  uterine  contraction  and 
abortion. 


48  PREGNANCY. 

What  are  the  disorders  resulting  from  mechanical  interference 
of  the  gravid  uterus  ?    Describe  them. 

(1)  Dyspnoea. — This  is  usually  present  to  a  slight  degree,  but  may  be 
so  excessive  as  to  prevent  the  patient's  sleeping  when  in  the  recumbent 
position. 

(2)  Varicose  Veins. — The  most  frequent  seat  of  these  is  on  the  inner 
sides  of  the  thighs  and  the  labia  majora.  They  occur  most  frequently 
in  multiparge,  and  are  caused  by  pressure  of  the  gravid  uterus  on  the 
abdominal  veins,  and  thus  an  impeded  return  flow  of  the  blood  from  the 
extremities.  As  a  rule,  they  give  no  trouble,  though  cases  occasionally 
arise  where  they  become  inflamed  and  extremely  painful.  The  treat- 
ment consists  of  rest  in  the  recumbent  position,  elevation  of  the  limbs, 
and  the  application  of  some  evaporating  lotion. 

(3)  Hemorrhoids. — Hemorrhoids,  though  aggravated  and  occasionally 
caused  by  constipation  accompanying  pregnancy,  are  frequently  seen 
where  this  condition  is  not  associated  with  gestation.  In  these  cases  the 
cause  is  simply  pressure  of  the  gravid  uterus  on  the  hemorrhoidal  veins. 
If  constipation  exists,  it  is  to  be  treated,  and  if  the  hemorrhoids  become 
very  troublesome,  the  application  of  an  ointment  containing  gallic  acid 
and  opium  will  affbrd  much  relief 

(4)  (Edema  of  the  Lower  Extremities. — This  is  of  no  consequence  if 
not  associated  with  albuminuria,  and  requires  no  treatment.  It  always 
disappears  after  labor.     If  very  excessive,  rest  relieves  it. 

(5)  IrritahiUty  of  the  Bladder. — As  a  rule,  this  does  not  occur  until 
toward  the  end  of  pregnancy,  but  may  be  met  with  at  the  outset.  It 
may  be  caused  by  some  abnormal  presentation  of  the  foetus,  and  is  re- 
lieved immediately  the  position  is  rectified.  If  not,  and  if  very  excessive, 
vaginal  suppositories  containing  opium  and  belladonna  will  often  give 
relief. 

Describe  briefly  the  disorders  affecting  the  circulatory  system. 

Anaemia. — This  is  due  to  the  alterations  in  the  blood  which  have 
already  been  described.  It  is  a  physiological  accompaniment  of  preg- 
nancy, and  as  a  rule  never  becomes  severe.  However,  it  may  at  times 
go  on  to  an  alarming  extent.  In  these  cases  the  onset  is  usually  insid- 
ious. The  face  becomes  colorless  and  slightly  puffy ;  oedema  of  the 
lower  extremities  begins,  and  may  become  general  or  even  invade  the 
serous  cavities.  The  patient  grows  weak  and  emaciated,  and  suft'ers 
from  sleeplessness,  dyspnoea,  headache,  vertigo,  and  frequent  attacks 
of  syncope.  On  examining  the  heart  a  systolic  murmur  is  heard,  usu- 
ally over  the  base,  though  sometimes  over  the  apex.  This  is  trans- 
mitted into  the  larger  vessels  of  the  neck. 

The  treatment  consists  in  regulating  the  diet  and  placing  the  patient 
under  the  most  favorable  hygienic  surroundings.  Iron  may  be  given 
combined  with  arsenic.  The  best  preparation  is  iron  reduced  by  hydro- 
gen in  gr.  j  to  iij  doses,  t.  i  d.     A  very  efficient  and  palatable  prepara- 


DISORDERS    OF    PREGNANCY.  49 

tion  is  the  so-called  iron  lemonade.  This  is  made  in  the  following  man- 
ner :  A  teaspoonf'ul  of  each  of  the  following  mixtures,  combined  with 
four  ounces  of  water  and  a  half  ounce  of  lemon-juice,  taken  three  or  four 
times  dail}^ : 

Citrate  of  iron,  3ij  ; 

Water,  ^iv.— M. 

Or,  Bicarbonate  of  potash,  3x ; 

Water,  ^  ^iv.— M. 

If  the  anaemia  persists  after  proper  and  thorough  treatment,  abortion 
or  premature  labor  must  be  induced. 

Diseases  of  the  Heart. — It  is  only  necessary  to  mention  the  fact  that 
pregnancy  has  a  decided  tendency  to  aggravate,  and  perhaps  hasten  the 
fatal  termination  in,  chronic  heart  lesions.  This  is  especially  marked  in 
cases  of  mitral  disease. 

Ascites. — A  cellular  infiltration  of  the  tissues  of  the  extremities  or 
other  parts  of  the  body  is  sometimes  found  during  pregnancy  from  the 
altered  condition  of  the  blood.  This  may  extend  to  the  pleural  or  peri- 
toneal cavities.  It  is  treated  by  removing  as  far  as  possible  the  cause, 
and  the  use  of  diuretics,  combined  with  rest  and  a  milk  diet. 

What  disorders  depending  upon  an  altered  innervation  are  met 
with  in  pregnancy? 

Ptyalism,  palpitation,  syncope,  insomnia,  mania,  neuralgia,  cephalalgia, 
paralyses,  cough,  pruritus,  and  eclampsia. 

Describe  each. 

Ptyalism,  or  salivation,  is  an  increased  activity  of  the  salivary  glands, 
and  thus  a  profuse  flow  of  saliva.  It  is,  as  a  rule,  confined  to  the  early 
months  of  pregnancy  if  it  occurs  at  all,  and  has  a  tendency  to  disappear 
spontaneously.  It  sometimes  becomes  exceedingly  annoying,  and  causes 
depression,  and  perhaps  interferes  with  proper  assimilation  of  the  food. 

Its  treatment  is  very  unsatisfactory.  Astringent  gargles  and  washes 
for  the  mouth,  the  chewing  of  quassia-chips  and  bitter  orange-peel,  and 
the  administration  of  atropine,  in  gr.  xiu  doses,  are  among  the  remedies 
used  to  relieve  it. 

Palpitation  and  Syncope  call  for  no  especial  treatment,  more  than  a 
proper  hygienic  regime. 

Insomnia  may  be  very  troublesome,  and  from  its  persistence  cause  ex- 
haustion, depression,  and  even  insanity.  Moderate  exercise,  early  retir- 
ing, and  the  avoidance  of  all  excitement  may  be  sufficient  to  relieve  it. 
If  not,  the  bromides  in  moderate  doses,  sulphonal,  chloral,  or  aniline 
hydrate  will  usually  produce  a  natural  and  healthy  sleep.  Opium  in  any 
form  is  contraindicated. 

Neuralgia  and  Headache  are  to  be  treated  as  when  met  with  under 
other  circumstances. 

4— Obs. 


50  PREGXANCY. 

All  forms  of  Paralysis  ma.y  be  met  with  in  pregnant  women  or  aftei 
delivery  has  taken  place.  They  always  have  a  marked  tendency  toward 
hemiplegia  or  paraplegia,  though  some  one  organ  of  special  sense  may 
be  involved,  or  the  paralysis  may  be  confined  to  the  limbs,  face,  or  some 
of  the  muscles.  Those  occurring  during  pregnancy  may  be  reflex  or  may 
have  a  uraemic  origin.  Others  are  due  to  cerebral  congestion,  and  there 
are  unquestionable  cases  of  a  purely  functional  character. 

The  prognosis  depends  upon  the  cause,  but  as  a  rule  is  good. 

The  treatment  depends  entirely  upon  the  cause.  Rest,  tonics,  strych- 
nine, massage,  and  electricity  have  all  been  employed. 

Coughs  are  purely  reflex,  and  for  them  antispasmodics  are  of  benefit 
Codeine  in  gr.  \  doses  is  good. 

Pruritus. — This  is  most  frequently  found  about  the  vulva,  but  may 
extend  over  the  entire  body  and  be  almost  unbearable.  If  this  is  the 
case,  it  is  usually  found  without  any  apparent  cause  and  is  of  neurotic 
origin.  This  also  may  be  the  case  where  observed  about  the  vulva,  but 
generally  an  aggravating  cause  will  be  found  in  the  leucorrhoeal  discharge 
which  is  so  often  met  with  in  pregnant  women. 

The  treatment  of  leucorrhoea,  if  present,  consists  in  thorough  cleanli- 
ness. If  erosions  are  found  on  the  cervix,  they  must  be  treated  by 
touching  with  a  solution  of  nitrate  of  silver.  Vaginal  douches  once  or 
twice  daily  of  carbolic-acid  solutions,  1  :  80  or  1  :  100,  a  solution  of 
borax,  5ss  to  Oj,  or  of  bichloride  of  mercury',  1  :  5000,  will  generally 
relieve  the  leucorrhoea.  External  applications  are  often  of  benefit  when 
the  pruritus  is  severe.  A  solution  of  AgNOg,  gr.  xx-5J,  painted  over 
the  vulva,  oftentimes  relieves  the  itching  immediatel}^  Cloths  wrung 
out  of  carbolic  acid,  1  :  100,  are  sometimes  efficient.  At  night  the 
patient  may  apply  to  the  vulva  a  pad  wrung  out  of  a  solution  containing 
the  following : 


Borax, 

3ij; 

Morph.  sulph., 

gr.  vij ; 

Rose-water, 

^vj; 

Dilute  hydrochloric  acid, 

3J.-M. 

When  the  pruritus  becomes  general  the  patient  should  be  thoroughly 
sponged  with  a  solution  of  bicarbonate  of  soda  and  water  and  put  upon 
her  back  in  bed.  The  diet  must  be  carefully  regulated,  and  large  doses 
of  the  bromides  are  said  to  have  been  used  with  decided  success. 

Chorea. — This  is  a  very  serious,  though  fortunately  not  a  frequent, 
complication  of  pregnancy.  It  is  usually  found  in  primii)am0  and  very 
young  patients,  and  in  many  cases  in(iuiry  will  reveal  the  fact  that  the 
patients  have  previously  suffered  from  the  disease.  It  generally  devel- 
ops during  the  early  months,  though  it  may  occur  any  time. 

The  symptoms  may  ai)pear  suddenly  or  come  on  slowly.  If  the  latter 
be  the  case,  there  is  first  noticed  slight  involuntary  movements  of  the 
face  or  limbs,  which  gradually  become  more  marked.     When  the  attack 


DISPLACEMENTS   OF   THE    UTERUS.  f51 

is  sudden  a  number  of  parts  are  simultaneously  involved.  There  are 
apt  to  be  exacerbations  and  remissions  of  the  disease.  During  sleep 
the  movements  cease,  to  reappear  again  when  the  patient  awakens  in 
the  morning.  There  may  be  a  weakening  of  the  memory,  though  as  a 
rule  this  is  not  impaired.  There  is  no  fever  and  no  digestive  disturb- 
ances. 

Treatment. — When  the  disease  develops  early,  there  is  little  chance 
of  the  pregnancy  going  on  to  term,  though  the  treatment  is  practically 
the  same  as  when  the  disease  is  found  under  ordinary  circumstances.  It 
consists  in  placing  the  patient  under  proper  hj'^gienic  surroundings  and 
giving  her  a  nutritious  diet.  Tonics  should  be  given,  combined  with 
bromides,  arsenic,  and  iron.  If  the  paroxysms  still  go  on  increasing  in 
severity,  abortion  or  premature  labor  must  be  induced. 

Uclariipsia  will  be  described  later  on. 

DISPLACEMENTS   OF   THE  UTERUS. 

What  displacements  of  the  gravid  uterus  are  met  with  during 
pregnancy  which  may  cause  grave  symptoms  ? 

Prolapse,  either  Complete  or  Iiicomp)lete. — This  is  a  very  rare,  though 
an  occasional,  occurrence. 

The  causes  are  the  pre-existence  of  prolapse,  multiparous  state,  trau- 
matism, justo-major  pelvis,  and  large  vulva.  In  many  cases,  as  the 
pregnancy  advances,  the~  prolapse  cures  itself  during  the  first  few 
months ;  in  others  it  is  the  means  of  causing  abortion. 

The  treatment  consists  in  replacing  the  uterus,  introducing  a  proper 
pessary,  and  enjoining  absolute  rest  in  the  horizontal  position. 

Anteversion. — Uterine  anteversion  is  merely  an  exaggeration  of  a  nor- 
mal state,  and  becomes  really  pathological  only  wdien  it  exceeds  a  certain 
limit  or  when  it  occurs  in  the  true  pelvis — i.  e.  in  the  first  months  of 
pregnancy  (Charpentier).  As  pregnancy  advances  when  the  condition 
exists  abnormally  it  produces  a  pendulous  abdomen.  The  anteversion 
may  reach  any  degree,  from  forming  simply  a  very  acute  angle  with  the 
pelvic  axis  to  reaching  the  symphysis  and  forming  nearly  a  right  angle. 
It  is  most  frequently  found  in  miiltiparge. 

The  symptoms  produced  are  marked  bladder  irritability,  pains  in  the 
back  and  loins,  and  excessive  constipation. 

The  treatment  is  mechanical,  and  consists  in  keeping  the  patient  at 
rest,  and,  if  the  abdomen  is  pendulous,  applying  some  form  of  abdomi- 
nal bandage  which  will  properly  support  it. 

Retroversion. — This  is  by  far  the  most  serious  of  the  uterine  displace- 
ments. It  rarely  occurs  before  the  third  or  after  the  fifth  month,  and  is 
most  frequent  between  the  third  and  fourth  months.  Two  forms  are 
described:  (1)  A  gradual  retroversion,  the  causes  of  which  are  the  oc- 
currence of  pregnancy  in  a  previously  retroverted  or  retroflexed  uterus, 
.justo-major  pelvis,  deformed  pelvis,  fibroid  and  ovarian  tumors,  and  ad- 
hesions from  an  old  peritonitis.     (2)  Sudden  retroversion  may  be  caused 


52  PREGNANCY. 

by  blows,  falls,  and  pressure  upon  the  abdomen,  but  usually  has  as  a 
predisposing  cause  some  of  the  conditions  stated  above. 

Symjytoms. — The  first  symptoms  noticed  are  marked  intestinal  and 
vesical  disturbances,  the  bladder  at  times  becoming  enormously  dis- 
tended. The  patient  complains  of  pain  in  hei-  back  and  limbs  and  a 
sense  of  weight  or  bearing-down  within  the  pelvis.  On  examination,  if 
the  labia  are  separated,  the  posterior  vaginal  wall  is  found  bulging  for- 
ward. The  cervix  is  felt  np  by  the  pubes  or  cannot  be  reached  at  all. 
From  the  excessive  distension  of  the  bladder  a  constant  dribbling  of 
urine  may  occur,  and  if  the  catheter  is  passed — which  is  always  very 
difficult  and  may  be  impossible — a  large  quantity  of  strong-smelling 
urine  is  withdrawn.  Three  results  may  now  follow :  1st.  The  uterus 
may  straighten  itself  spontaneously  and  rise  out  of  the  pelvis — a  fortu- 
nate but  rare  occurrence.  2d.  The  uterus  becomes  incarcerated  within 
the  pelvis,  congestion  and  inflammation  follow,  with  fever,  prostration, 
vomiting,  irregular  and  feeble  pulse,  exhaustion,  and  death;  or  from 
the  extreme  distension  of  the  bladder  this  organ  ruptures,  causing  a 
fatal  peritonitis.  In  some  cases  the  urinary  elements  are  retained,  and 
death  from  uraemia  follows.     3d.  The  woman  may  abort. 

The  diagnosis  is  made  by  feeling  no  fundus  on  abdominal  palpation, 
and  when  a  digital  examination  is  made  the  finding  of  a  hard  round 
mass  pushing  forward  the  posterior  vaginal  wall.  Then  if  the  cervix 
can  be  felt  at  all,  it  will  be  back  of  the  pubes. 

Treatmeut. — As  soon  as  the  condition  is  discovered  the  uterus  should 
be  replaced.  Finding  this  impossible,  the  only  resource  is  to  induce 
abortion.  To  replace  the  retroverted  uterus  the  patient  should  be 
placed  in  the  knee-chest  position  and  pressure  made  on  the  fundus  in 
an  upward  direction.  Failing  in  this,  anresthetize  the  patient,  and  with 
two  fingers  in  the  rectum  push  the  fundus  upward.  This  is  facilitated 
by  drawing  the  cervix  downward  by  means  of  the  finger  and  thumb  of 
tiie  other  hand  introduced  into  the  vagina,  or,  if  this  cannot  be  done, 
by  the  use  of  the  tenaculum. 

ALBUMINURIA. 

What  forms  of  albuminuria  are  met  with  ? 

( 1 )  Alljuniiiiuria  in  pregnant  women  with  pre-existing  renal  lesions  ; 
(2)  Idiopathic  albuminuria;   (3)  All^uniinuria  complicating  labor. 

When  does  it  usually  make  its  appearance? 

(Tcnerally  not  before  the  end  of  the  third  month,  and  most  frequently 
about  tlie  sixth  month. 

What  are  the  causes  of  puerperal  albuminuria  ? 

(I)  ]*ressure  of  the  gravid  uterus  on  the  renal  veins.  This  hardly 
seems  i)lausible  during  the  early  months,  as  tlie  uterus  has  not  reached 
a  size  sufficiently  large  to  cause  pressure  upon  these  vessels.     Later  in 


ALBUMINURIA.  53 

pregnancy  this  may  be  one  of  the  causes.  (2)  Pressure  upon  the  ureters 
by  the  uterus.  (3)  High  arterial  tension,  due  to  the  hydrsemic  condition 
of  pregnant  women.  (4)  High  degree  of  nervous  irritabihty.  (5j  Re- 
flex irritabihty,  associated  with  the  glandular  secretions. 

Describe  the  course,  symptoms,  prognosis,  and  treatment. 

1.  In  the  Ordbiary  Insidious  Cases. — The  first  and  only  positive 
symptom  is  the  presence  of  albumin  in  the  urine.  The  patient  usually 
becomes  somewhat  anaemic,  and  an  oedema  of  the  extremities,  often- 
times extending  to  the  face  and  neck,  is  observed.  Headache  is  usually 
frontal  and  constant,  though  it  may  not  be  severe  and  may  be  confined 
to  one  side  onlj^  Ringing  in  the  ears  is  a  constant  and  annoying  sj^mp- 
tom  if  the  albumen  becomes  large  in  amount.  Visual  disorders  are  ob- 
served, such  as  double  or  blurred  vision  and  black  spots  before  the  eyes. 
Vomiting,  continuing  throughout  the  day,  and  in  women  who  have  not 
previously  been  .sufiering  from  nausea.  Excessive  nervous  irritability 
and  neuralgic  pains,  or  at  times  some  form  of  paralysis.  The  pulse  is 
small,  hard,  and  rapid.  If  the  patient  remains  without  treatment,  these 
symptoms  become  more  marked.  Vertigo  and  dizziness  appear,  and  the 
visual  disturbances  become  more  and  more  severe,  until  at  times  blind- 
ness results.  Digestive  disturbances  are  very  pronounced,  and  the 
patient  has  an  acute  attack  of  indigestion  and  an  eclamptic  seizure. 

Prognosis. — The  prognosis  for  the  child  is  always  grave,  especially  if 
the  disease  is  persistent  or  far  advanced  when  treatment  is  begun.  The 
prognosis  for  the  mother  is  good  if  she  is  seen  early. 

Treatment. — (1)  Regulate  the  diet.  This  should  consist  exclusively 
of  milk,  the  patient  taking  three  or  four  quarts  daily.  If  the  symptoms 
are  very  persistent  and  the  urine  scanty,  skimmed  milk,  having  more  of 
a  diuretic  action,  is  preferred.  (2)  Insist  that  the  patient  wear  flannels 
next  to  the  skin  :  they  need  not  be  heavy,  but  must  be  roomy  and  warm. 
(3)  Regulate  her  mode  of  life,  so  that  she  shall  take  a  proper  amount  of 
exercise  and  have  plenty  of  fresh  air.  All  excitement  must  be  avoided. 
Her  sleeping-room  should  be  large  and  well  ventilated,  though  care  must 
be  taken  to  avoid  draughts  or  chilling  of  the  body.  (4)  Medicinal — 
This  consists — 1st,  in  drugs  which  reduce  the  congestion  of  the  kidney 
and  lower  the  arterial  tension ;  and  2d,  in  those  used  to  allay  the  nervous 
irritability.  Among  the  first  class  the  most  important  are  laxatives. 
Compound  licorice  powder  or  an  occasional  dose  of  compound  jalap 
powder  is  efficient,  but  perhaps  best  of  all  are  the  saline  cathart,  or 
mineral  waters,  given  every  other  morning.  Of  the  former,  citrate  of 
magnesia,  sulphate  of  magnesia,  and  Rochelle  salts  are  best.  If  the 
latter  are  used,  Hunj^adi  and  Villicabras  are  very  excellent.  Digitalis 
in  small  doses,  combined  with  the  acetate  or  citrate  of  potash,  makes 
a  very  good  diuretic  mixture.  If  the  anaemia  is  marked,  the  so-called 
iron  lemonade  already  spoken  of  is  indicated.  Among  the  drugs 
given  for  nervous  irritability  the  bromides  are  by  far  the  best.  After 
a  thorough  trial  of  treatment  with  no  improvement  in  the  patient's 


54  PREGNANCY. 

symptoms  and  general  condition,  the  only  resource  is  to  induce  abortion 
or  premature  labor. 

2.  In  Acute  Albmnuinria. — In  this  the  outset  is  very  sudden  and 
severe.  As  a  rule,  it  does  not  occur  until  the  latter  months  of  gestation 
— never  until  after  the  fourth  month — and  is  usually  seen  in  plethoric 
women.  All  the  symptoms  given  above  are  present,  but  are  more 
marked  and  severe.  The  urine  becomes  scanty,  high-colored,  and  may 
contain  epithelial  scales  and  hyaline  and  graimlar  casts.  The  pulse  is 
full  and  bounding  and  almost  incompressible.     Vomiting  is  persistent. 

The  prognosis  in  these  cases  is  good  if  the  symptoms  yield  readily  to 
treatment.     If  not,  it  is  very  bad. 

Treatment. — If  the  patient  be  plethoric  and  pulse  full  and  hard,  ab- 
stract 12  or  14  ounces  of  blood  from  the  arm.  Then  give  a  pure  purga- 
tive— comp.  jalap  powder  in  dose  of  gr.  xl-3j  or  calomel  in  gr.  x-xx 
doses,  combined  with  soda  bicarbonate.  Keep  patient  quiet  and  in  bed, 
allow  only  milk,  and  if  she  is  at  all  restless  give  her  the  bromides.  The 
most  satisfactory  salt  is  the  bromide  of  soda  in  gr.  xx-xl  doses,  combined 
with  chloral  hydrate,  gr.  v-xv.  If  the  symptoms  subside,  this  will  be 
all  that  is  necessary.  If  not — and  very  rapidly  too,  for  in  these  cases 
there  is  great  danger  of  eclampsia — induce  labor.  But  always  try,  if 
possible,  to  wait  until  the  child  is  viable. 

ECLAMPSIA. 
"What  is  eclampsia? 

Eclampsia  is  an  acute  disease  coming  on  during  pregnancy,  labor,  or 
the  puerperal  state,  and  characterized  by  a  series  of  tonic  and  clonic  con- 
vulsions, affecting  at  first  the  voluntary  muscles,  and  finally  extending  to 
the  involuntary  muscles,  accompanied  by  a  complete  loss  of  conscious- 
ness and  ending  by  a  period  of  coma  or  sleep  (Charpentier).  It  is  more 
frequent  during  pregnancy  and  labor  than  after  delivery. 

What  is  the  etiology  of  eclampsia  ? 

Although  all  cases  of  albuminuria  are  not  accompanied  by  eclampsia, 
the  latter  is  probably  always  preceded  by  or  accomi)anied  with  albumi- 
nuria; hence  it  is  by  most  supposed  that  the  disease  is  one  of  the  mani- 
I'estations  of  albuminuria.  Primiparity  is  certainly  a  very  decided  pre- 
disposing cause,  as  is  also  an  excessively  distended  uterus  either  irom  a 
multiple  gestation  or  hydranmion.  The  immediate  cause  of  the  con- 
vulsion has  been  variously  stated  by  different  authors.  Some  have  said 
that  it  is  due  to  a  cereljro-spinal  congestion  ;  others,  that  it  is  a  neurosis 
caused  by  reflex  irritation  of  the  si)inal  system;  others,  still,  believe  that 
eclampsia  depends  ui)oii  a  poisoning  of  tlie  blood  which  renders  it  too 
impure  to  i)roperly  stimulate  the  nerve-centres;  in  otlu^r  words,  that  by 
the  impure;  blood  the  nervous  system  is  prai^tically  poisoned.  This  is 
the  most  generally  accepted  theory,  though  what  the  poison  is,  whether 
urea  or  some  other  ingredient,  is  not  known. 


ECLAMPSIA.  55 

Describe  an  eclamptic  seizure. 

The  attack  will  usually  be  preceded  b}^  some  of  the  symptoms  spoken 
of  under  the  head  of  Albuminuria,  such  as  oedema,  vertigo,  insomnia, 
cephalalgia,  stupor,  or  blindness.  The  patient  first  feels  a  sense  of  dizzi- 
ness, and  if  closely  observed  it  will  be  noticed  that  the  thumbs  are  turned 
inward  across  the  palms  of  the  hands.  The  head  now  turns  to  one  side 
or  in  a  backward  direction ;  the  eyeballs  roll  upward,  so  that  only  the 
sclerotics  can  be  seen,  and  the  angles  of  the  mouth  are  drawn  downward, 
giving  the  face  a  horrible  expression.  The  face,  which  is  at  first  very  pale, 
now  becomes  deeply  cyanotic,  the  glottis  closes,  and  the  veins  of  the  neck 
are  enormously  swollen.  The  carotids  pulsate  violently.  This  tonic  rigidity 
lasts  from  ten  to  twenty  seconds,  when  the  clonic  spasms  begin.  The 
hands  open  and  close,  a  violent  twitching  of  the  limbs  and  arms  occurs, 
and  the  whole  muscular  system  is  thrown  into  rapidly  recurring  convul- 
sive movements.  Respiration  is  hurried  and  shallow,  and  is  accompanied 
by  a  frothing  at  the  mouth.  This  usually  lasts  no  longer  than  three  to 
five  minutes,  and  is  followed  by  a  condition  of  coma.  In  a  few  minutes 
the  woman  opens  her  eyes,  but  nothing  is  distinct,  and  when  conscious- 
ness is  regained  she  has  no  recollection  of  what  has  taken  place.  It 
sometimes  happens  that  the  coma  becomes  deeper  and  the  patient  dies 
without  recovering  consciousness.  When  she  recovers  from  a  convulsion 
she  is  so  extremely  irritable  that  the  slightest  noise,  or  even  draught  of 
cold  air,  will  immediately  throw  her  into  another  convulsion.  The  remis- 
sions or  periods  between  the  seizures  are  variable.  Sometimes  but  a  few 
minutes  intervene,  while  at  others  several  hours  may  pass  before  a  second 
attack  occurs.  There  may  be  but  one  or  two  attacks  or  there  may  be 
sixty  or  eighty. 

What  is  the  prognosis  of  eclampsia? 

If  the  temperature  rises,  the  attacks  are  frequently  repeated,  and  the 
introduction  of  a  catheter  brings  away  only  a  small  quantity  of  high-col- 
ored urine ;  the  prognosis  is  somewhat  variable,  although  it  is  alwaj^s 
bad.  After  delivery  has  taken  place  it  is  better,  and  the  later  in  preg- 
nancy it  occurs  the  better  the  prognosis.  About  40  per  cent,  of  the  cases 
recover.     To  the  child  the  prognosis  is  always  very  grave. 

What  is  the  treatment  of  eclampsia  when  it  occurs  before  labor 
has  begun? 

Immediately  after  the  convulsion  begins  crowd  a  towel  between  the 
teeth  to  prevent  biting  the  tongue,  loosen  all  the  clothing,  and  give 
plenty  of  fresh  air.  Do  not  restrain  the  patient,  but  allow  her  to  thrash 
about  as  much  as  she  pleases  upon  the  bed  ;  only  keep  her  from  falling 
out.  As  soon  as  the  tonic  spasm  has  passed  let  her  inhale  chloroform, 
but  not  to  the  surgical  degree.  When  she  is  well  out  of  the  convulsion 
rupture  the  membranes  and  give  a  purge,  preferably  elaterine,  gr.  i, 
comp.  powder  jalap,  .5ss-j,  or  calomel,  gr.  x-xx:  if  necessary,  croton 
oil,  ^-ij,  in  olive  oil,  .5j.     If  the  patient  be  plethoric  with  a  bounding 


56  PREGNANCY. 

pulse,  abstract  ^xij-xv  of  blood  from  her  arm,  and  give  morphine  sul- 
phate, gr.  T,  hypodermically,  and  repeat  frequently  enough  to  keep  her 
well  under  its  influence.  Then  soak  a  blanket  in  hot  water,  and  wind 
this  around  the  patient,  covering  with  two  dry  blankets.  Keep  her  in 
the  pack  three  to  four  hours,  and  after  taking  her  from  it  give  chloro- 
form and  pass  the  catheter.  If  the  patient  has  now  been  quiet  for  a  few 
hours  and  the  kidneys  and  bowels  are  acting  well,  and  if  the  uterine  con- 
tractions have  not  begun,  a  catheter  may  be  introduced  into  the  uterus 
to  start  the  labor.     During  the  pains  always  give  chloroform. 

Describe  the  treatment  when  a  seizure  occurs  during  labor. 

Administer  chloroform  freely,  and  if  the  membranes  are  intact  rup- 
ture them.  This  is  often  sufficient  to  check  further  convulsions.  It  is 
still  a  disputed  point  as  to  whether  or  not  delivery  should  be  hastened 
when  the  pains  are  forcible  and  efficient.  This  must  be  decided  in  each 
individual  case. 

How  would  you  treat  a  case  occurring  after  delivery? 

Give  chloroform  enough  to  produce  anaesthesia,  then  administer  mor- 
phine hypodermically,  or  chloral  hydrate,  gr.  xx,  and  sodium  bromide, 
3ss,  by  mouth  or  enema ;  produce  free  purgation,  and  keep  the 
patient  on  milk  diet  until  the  albumin  has  disappeared  from  the  urine. 

What  should  be  the  after-treatment  of  eclampsia  ? 

Milk  diet  until  albumin  has  disappeared,  iron— and  as  good  a  form 
as  can  be  given  is  the  iron  lemonade — tonics,  fresh  air,  favorable  hygienic 
surroundings,  and  nourishing  food. 

DISEASES   OCCURRING   WITH  PREGNANCY. 

Naturally,  the  pregnant  woman  may  contract  any  disease  she  would 
contract  in  the  non-pregnant  state,  but  as  some  diseases  are  very  materi- 
ally influenced  by  this  condition,  they  will  be  spoken  of 

What  influence  has  pregnancy  on  the  eruptive  fevers? 

Wlien  associated  with  gestation  the  eruptive  fevers  are  usually  very 

severe. 

In  small-pox  would  the  woman  abort? 

If  the  type  is  severe,  and  especially  if  the  temperature  be  high,  the 
foetus,  as  a  rule,  dies  and  is  soon  expelled.  On  the  other  hand,  preg- 
nancy may  continue,  and  on  the  birth  of  the  child  jiitting  will  be  found 
to  show  it  to  have  suffered  from  the  disease  in  utero.  Cases  are  recorded 
of  children  having  been  born  with  small- pox.  The  confluent  form  is 
almost  invariably  fatal  both  to  mother  and  child. 

What  can  you  say  of  scarlet  fever  and  pregnancy  ? 

Scarlet  fever  usually  assumes  a  malignant  type,  and  almost  invariably 


EXTRA-UTERINE   PREGNANCY.  57 

causes  abortion.     When  this  does  occur  death  usually  results  from  sep- 
ticaemia, as  the  scarlet-fever  germs  cause  this  disease. 

What  can  you  say  of  pneumonia  ? 

This  disease,  when  it  does  occur,  is  generally  very  fatal,  both  to  mother 
and  child.  On  account  of  the  high  and  continuous  febrile  movement 
abortion  is  likely  to  result.  This  is  especially  true  when  the  pregnancy 
is  far  advanced,  and  the  more  advanced  the  pregnancy  the  more  likely 
is  the  pneumonia  to  terminate  fatally.  , 

What  can  you  say  of  phthisis  ? 

This  disease  is  probably  aggravated  by  pregnancy,  notwithstanding 
many  opinions  and  views  to  the  contrary  ;  and  it  is  certain  that  the  off- 
spring of  tuberculous  mothers  is  in  many  cases  either  scrofulous  or  tuber- 
culous. Then,  again,  there  is  a  greater  tendency  to  abortion  or  prema- 
ture labor  in  phthisical  mothers. 

What  can  you  say  of  syphilis  ? 

Syphilis  may  exist  before  conception :  it  may  be  contracted  during 
gestation  or  at  the  time  when  conception  takes  place.  In  all  these  cases 
there  is  a  tendency  to  abortion,  but  the  tendency  is  more  marked  in 
cases  where  syphilitic  women  become  pregnant.  Exceptionally,  the 
child  is  born  in  a  healthy  condition,  and  remains  so.  More  frequently, 
however,  it  shows  evidences  of  the  disease  at  birth  or  develops  symptoms 
within  a  few  months. 

EXTRA-UTERINE  PREGNANCY. 
What  different  forms  of  extra-uterine  pregnancy  are  met  with  ? 

(1)  Tubal,  of  which  there  are  several  varieties — viz.  tubal  proper,  in- 
terstitial, tubo-ovarian,  and  subperitoneal;  (2)  abdominal;  (3)  "ova- 
rian;" (4)  pregnancy  in  a  bilobed  uterus  ;  (5)  pregnancy  in  a  hernial  sac. 

What  are  the  causes  of  ectopic  gestation  or  extra-uterine  preg- 
nancy ? 

These  abnormal  pregnancies  usually  occur  after  thirty  years  of  age, 
and  in  women  who  have  long  been  sterile,  and  are  caused  by  anything  in- 
terfering with  the  passage  of  the  ovule  through  the  tube  from  the  ovary  to 
the  uterus.  Among  these  may  be  mentioned  inflammatory  conditions 
of  the  tube,_  a  narrowing  of  its  calibre  from  old  pelvic  inflammations, 
tumors  causing  compression  of  the  tube,  polypi,  etc.  Fright  or  excite- 
ment is  also  thought  by  some  to  be  a  cause.  The  abdominal  variety  may 
be  caused  by  the  rupture  of  the  sac  of  an  ovarian  or  tubal  pregnancy  or 
by  the  failure  on  the  part  of  the  fimbriae  to  grasp  the  ovule  as  it  leaves 
the  ovary,  thus  allowing  it,  after  it  has  become  impregnated,  to  fall  into 
the  abdominal  cavity.  Some  say  it  may  become  impregnated  by  the 
passage  of  the  semen  through  the  tube  and  into  the  peritoneal  cavity. 


58  EXTRA -UTERINE    PREGNANCY. 

Describe  the  natural  course  of  a  tubal  pregnancy. 

The  ovum  is  arrested  in  some  part  of  the  tube,  and  begins  to  develop 
just  as  in  a  normal  pregnancy.  The  chorion  develops,  and  upon  it  the 
villi  appear,  but  no  decidua  is  formed  around  the  foetus.  However,  this 
is  found  in  the  uterus  as  in  a  normal  pregnancy.  No  proper  placenta  is 
ever  found.  This  may  be  due  to  the  fact  that  rupture  usually  occurs 
before  the  time  when  it  should  appear.  For  a  time  the  ovum  grows, 
but  soon  the  tube  has  expanded  to  its  fullest  extent ;  its  fibres,  by  the 
prolonged  and  excessive  stretching,  draw  apart ;  the  tension  from  within 
causes  the  coverings  to  rupture  ;  and  the  patient  dies  either  from  shock, 
hemorrhage,  or  peritonitis. 

State  the  symptoms  and  diagnosis  of  a  tubal  pregnancy. 

Exactly  the  same  symptoms  as  occur  in  a  normal  pregnancy  may  be 
present,  but,  as  a  rule,  those  which  are  developed  during  the  early 
months  are  the  only  ones  ever  seen,  and  these  are  very  much  aggravated. 
The  nausea  and  vomiting  begin  very  early,  sometimes  within  a  few  days 
of  conception,  and  the  latter  may  be  uncontrollable.  Menstruation  may 
cease,  but  at  times  during  a  menstrual  epoch  there  is  a  sero-sanguineous 
discharge  containing  shreds  of  tissue  (the  decidua).  Colicky  pains  ap- 
pear in  one  side  or  another,  and  are  severe.  They  may  be  accompanied 
by  pains  passing  down  the  thighs,  and  inability  to  walk  without  great 
difficulty.  The  uterus  enlarges  somewhat,  the  cervix  softens,  the  mam- 
mary changes  are  present,  and  all  the  symptoms  of  a  normal  pregnancy 
are  seen. 

Dinr/noshs. — On  examination  is  noticed  an  excessively  congested  and 
red  vaginal  mucous  membrane.  The  cervix  is  soft,  and  the  uterus  larger 
than  normal,  but  there  is  not  the  tendency  of  it  to  lie  over  on  the  bladder 
as  it  always  docs  in  an  ordinary  pregnancy ;  hence  the  bladder  irritability 
is  not  noticed.  In  the  abdomen  is  found  a  tumor,  which,  unlike  the 
uterus,  lies  to  one  side  of  the  median  line,  and  is  painful  on  pressure. 
The  above.  accomi)anied  by  the  colicky  pains  already  described  and  the 
menstrual  flow,  should  always  lead  one  to  strongly  suspect  an  abnormal 
pregnancy,  though  a  positive  diagnosis  may  be  extremely  difficult  unless 
a  scjund  is  introduced  into  the  uterus,  which  will  show  this  organ  to  be 
empty. 

When  does  this  form  of  pregnancy  usually  rupture  if  not  inter- 
fered with  ?  and  what  are  the  symptoms  of  rupture  ? 

Rupture  usually  occurs  between  the  first  and  third  months,  though  it 
may  take  place  as  early  as  the  second  week,  and  cases  are  recorded 
where  it  has  been  delayed  until  the  sixth  month. 

The  si/i)ii>fonis  of  rui)ture  of  the  tube  arc  those  of  extreme  collapse, 
and  with  this  may  be  associated  severe  alxloniinal  paiiis,  pallor,  cold  ex- 
tremities, a  small,  thready,  and  raj)id  puls(;;  vomiting,  and  possibly 
coma,  accompanied  by  ''air  hunger"    and  restlessness,  may  be  seen, 


TUBAL.  59 

followed  bj'  death  almost  immediatelj'  ;  or  these  sj^mptoms  may  not  be 
so  marked,  and  the  patient  rallies  onl}^  to  develop  a  violent  general  peri- 
tonitis, which  results  in  death. 

How  should  a  tubal  pregnancy  be  treated? 

If"  the  case  is  seen  before  rupture  has  taken  place,  there  are  several 
methods  of  treatment  which  have  been  pursued  with  varied  success. 
One  is  to  destroy"  the  foetus.  This  has  been  done  by  means  of  the 
faradic  current,  which  may  be  administered  ten  or  fifteen  minutes  daily 
for  a  week  or  two.  Tf  the  tension  is  removed  and  the  cyst  ceases  to  en- 
large, it  may  be  known  that  the  child  is  dead.  Then  there  is  hope  that 
it  may  remain  inert  in  the  tube.  Another  method  of  accomplishing  the 
same  end  is  the  use  of  the  galvanic  current,  the  negative  electrode  being 
introduced  into  the  vagina  and  pressed  up  against  the  tumor,  while  the 
positive  is  placed  over  the  abdomen.  Morphine  and  strychnine  have 
also  been  injected  into  the  sac  to  destroy  the  child,  and  with  success  in 
some  instances.  Probably  the  most  modern  and  successful  treatment  is 
to  do  a  laparotom^^  and  remove  the  tube.  If  rujDture  has  taken  place, 
the  only  rational  procedure  is  to  stimulate  the  patient  and  perform  a 
laparotomy,  removing  the  blood,  foetus,  and  tube. 

Describe  the  course,  symptoms,  and  treatment  of  an  abdominal 
pregnancy. 

This  form  of  extra-uterine  pregnancy  generally  goes  to  fall  term,  while 
the  tubal  variety  never  does.  The  placenta  forms  on  the  peritoneum  and 
adhesions  are  usually  set  up.  The  s^'mpathetic  disturbances  met  with  in 
a  normal  pregnancy  are  all  present.  Menstruation  may  cease,  but  usually 
this  is  not  the  case,  or  if  it  does  it  ceases  only  for  a  short  time ;  and  it 
may  be  regular  throughout.  At  times  conception  may  occur  again,  and 
the  woman  bear  a  child  to  term  in  the  uterus.  Infrecjuent  colicky  pains 
are  met  with,  but  are  not  usually  as  severe  as  in  the  tubal  variety.  On 
examining  the  uterus  it  will  be  found  but  shghtly  enlarged,  though  the 
cervix  is  soft  as  in  a  normal  pregnancy.  The  introduction  of  a  sound 
shows  the  uterus  to  be  empty.  The  foetal  heart-sounds  will  be  present  and 
very  loud.  Palpation  reveals  the  presence  of  the  small  parts  of  the  child 
just  beneath  the  hand.  These  cases  may  set  up  a  peritonitis  which  re- 
sults in  the  death  of  the  mother,  or  they  may  go  on  to  full  term,  giving 
no  real  marked  symptoms  at  any  time.  In  the  latter  case  a  pseudo-labor 
occurs.  Regular  uterine  contractions  take  place,  lasting  for  a  variable 
length  of  time,  and  the  foetus  dies.  When  this  occurs  a  retrograde  action 
begins :  the  breasts  and  uterus  atrophy,  as  also  do  the  foetus  and  pla- 
centa. The  liquor  amnii  may  become  absorbed,  and  the  coverings  of  the 
foetus  are  clearly  adherent  to  it,  or  maceration  of  the  child  may  occur. 
Occasionally  in  the  former  cases  the  foetus  is  carried  for  years,  and  even 
a  long  lifetime,  without  causing  any  symptoms.  As  a  rule,  putrefaction 
results,  and  a  peritonitis  or  septicaemia  is  set  up,  or  a  secondary'  inflam- 
mation takes  place  and  the  foetus  is  discharged  piecemeal  through  the 


60  MULTIPLE    PREGNANCY. 

abdominal  wall,  vagina,  bowel,  or  bladder,  most  frequently  through  the 
abdominal  wall. 

Treatment. — If  the  diagnosis  has  been  made  certain,  the  treatment 
resolves  itself  into  one  of  two  courses : 

1.  Primary  Laparotomy. — If  done  at  all,  this  should  be  done  when 
the  child  is  at  full  term.  The  statistics  in  these  cases  are  not  at  all  favor- 
able, though  some  good  results  have  been  obtained.  It  maj^  be  justifiable 
in  some  cases,  and  when  it  is  done  it  is  with  the  hope  that  adhesions  may 
be  found  between  the  peritoneum  and  cyst.  The  placenta  should  not  be 
removed,  but  left  to  discharge  through  the  wound,  a  portion  of  which  is 
left  open.  If  no  adhesions  are  found,  the  peritoneum  must  be  stitched 
to  the  abdominal  wall.  Cut  the  cord  as  near  the  placenta  as  possible. 
The  operation  is  almost  invariably  followed  by  septicaemia,  but  this  may 
be  of  such  a  mild  form  that  recovery  will  take  place. 

2.  Secondary  Laparotomy. — If  this  is  decided  upon  either  through 
choice  or  necessity,  an  incision  is  to  be  made  where  the  mass  points, 
whether  this  be  through  the  abdominal  wall,  vagina,  or  rectum,  and 
afterward  the  sac  is  washed  out  frequently  with  some  antiseptic  solution. 
Some  have  recommended  the  opening  of  the  cyst  by  caustics  when  there 
is  reason  to  believe  that  adhesions  are  not  present. 

What  is  "missed  labor"? 

This  term  is  given  to  a  class  of  extremely  rare  cases  of  utero-gestation 
in  which  the  foetus  is  retained  in  the  uterus  for  a  variable  length  of  time 
beyond  term.  Labor-pains  begin  and  cease,  or  may  never  come  on  at 
all;  the  foetus  dies  and  becomes  decomposed,  setting  up  a  peritonitis,  or 
it  is  expelled  in  pieces ;  or,  as  in  abdominal  pregnancies,  cases  are  re- 
corded where  decomposition  has  not  occurred,  and  the  foetus  has  re- 
mained in  the  uterus  for  years,  causing  no  untoward  symptoms.  The 
cause  or  causes  of  this  occurrence  are  not  well  understood. 

MULTIPLE    PREGNANCY. 

What  can  you  say  of  the  frequency  of  multiple  pregnancies  ? 

This  varies  considerably  in  different  countries  and  among  different 
races.  Statistics  have  shown  it  to  occur  most  frequently  in  Russia, 
where  the  proportion  of  twin  to  single  gestations  is  about  1  to  50 ;  how- 
ever, the  average  is  from  1  in  80  to  1  in  90  pregnancies. 

State  the  causes  of  multiple  pregnancies. 

They  are  three  in  number:  (J)  Two  Graafian  follicles  mature  simul- 
taneously, and  each  expels  an  ovule  which  becomes  impregnated.  They 
may  botli  come  from  the  same  ovary  or  one  from  each.  (2)  One  Graaf- 
ian follicle  containing  two  mature  ova  which  become  simultaneously  im- 
pregnated. This  is  a  double-yelked  egg,  as  it  were.  (3)  A  single  fol- 
licle, a  single  ovum,  but  two  nuclei. 


SUPERFCETATION    AND   SUPERFECUNDATION.  61 

In  twin  pregnancies  are  the  children  likely  to  be  of  the  same 
sex? 

The  most  frequent  combination  is  a  male  and  female ;  the  next  in 
frequency  is  two  females ;  and  the  least  frequent  two  males. 

How  are  the  placentae  and  membranes  arranged  in  twin  gesta- 
tions ? 

(1)  When  two  ova  become  impregnated,  each  one  develops  independ- 
ently, and  the  result  is  two  separate  chorions,  two  amnions,  two  placentae, 
and  two  cords.  Occasionally  it  happens  that  the  placentae  lie  very  close 
together,  and  eventually  unite,  but  a  thin  line  of  union  can  invariably 
be  seen. 

(2)  A  single  Grraafian  follicle,  but  two  ovules.  In  this  case  there  are 
two  amnions,  but  only  a  single  chorion.  The  placentas  are  usually  united, 
and  from  this  come  two  cords, 

(3)  One  ovule  with  two  nuclei.  In  these  cases  there  is  a  single  am- 
nion, a  single  chorion,  and  one  placenta  with  two  cords.  The  vessels  in 
these  instances  are  apt  to  anastomose  in  the  placenta. 

SUPERFCETATION  AND   SUPERFEOUNDATION. 
What  is  superfcetation  ? 

By  this  term  is  meant  the  impregnation  of  a  second  ovule  when  the 
uterus  already  contains  one  impregnated  ovum.  This  must  occur  very 
early  in  pregnancy,  else  it  is  called  superfecundation.  The  fact  that  it  is 
possible  is  proven  by  the  occurrence  of  twins  of  different  nationalities  or 
races  being  born  to  one  woman. 

What  is  superfecundation  ? 

Superfecundation  means  the  impregnation  of  a  second  ovule  in  a 
uterus  containing  an  ovum  somewhat  developed.  The  possibility  of  this 
occurrence  is  proven  in  two  ways:  (1)  By  the  fact  that  in  some  twin 
pregnancies  one  child  is  apparently  at  full  term,  while  the  other  is  seem- 
ingly premature.  However,  this  is  not  a  very  good  reason,  as  we  know 
that  the  growth  of  two  children  in  utero  may  not  be  equally  rapid.  One 
seems  to  take  more  of  the  nourishment,  as  it  were.  (2)  A  full-term 
child  is  born  to  a  woman,  and  in  a  few  months  she  gives  birth  to  another, 
apparently  mature,  foetus. 

DISEASES   OF   THE   OVUM,  FCETUS,  AND  DEOIDUA. 
What  pathological  conditions  of  the  decidua  are  met  with  ? 

Acute  inflammations  are  occasionally  seen  accompanying  the  infectious 
diseases.  These  almost  invariably  lead  to  abortion,  and  are  not  nearly 
as  frequent  as  is  the  chronic  condition  of  endometritis.  There  are  three 
forms : 

(1)   Chronic  Diffuse  Endometritis^  which  consists  in  the  formation  of 


62         DISEASES   OF   THE   OVUM,    FCETUS,    AND   DECIDUA. 

a  jiew  connective  tissue,  making  a  much-thickened  decidua  if  the  preg- 
nancy continues.  It  very  frequently  happens  that  the  endometritis  ex- 
ists when  impregnation  occurs,  and  in  these  cases  abortion  will  be  very 
apt  to  result  at  an  early  stage. 

(2)  Polypoid  Endometritis. — In  these  cases  there  is,  besides  the  thick- 
ening of  the  mucous  membrane,  a  growth  upon  its  surface  of  small, 
smooth  bodies,  varying  greatly  in  size  and  number,  called  polypoids. 
Pregnancy  may  go  on  to  term,  and  the  condition  be  discovered  only  after 
labor,  or  the  growths  may  be  so  abundant  as  to  interfere  with  the  nutri- 
tion of  the  foetus,  causing  its  death,  and  abortion  results, 

(3)  Catarrhal  Endometritis  or  Hydrorrhoea  Gravidarum  (?).^ — This 
is  the  collection  of  an  aqueous  fluid  somewhere  in  the  uterine  cavity  and 
its  discharge  by  the  vagina.  The  cause  is  unknown.  Many  believe  it  to 
be  a  rapid  secretion  from  the  uterine  glands,  and  for  this  reason  it  has 
been  classed  with  the  forms  of  endometritis.  If  this  be  the  case,  the 
fluid  collects  between  the  decidua  and  chorion.  Some  think  the  accu- 
mulation is  between  the  chorion  and  amnion  ;  others,  that  it  lies  in  a  sac 
or  cyst  between  the  two  membranes. 

The  diagnosis  of  this  condition  can  only  be  made  from  a  history  of 
repeated  watery  discharges,  no  uterine  contractions,  and  a  tightly-closed 

OS. 

Treatment  is  not  called  for,  as  neither  the  pregnancy  nor  the  health 
of  the  mother  or  child  is  in  any  way  interfered  with. 

THE   PLACENTA. 
Describe  placentitis. 

This  pathological  condition  may  be  caused  by  disease  of  the  decidua 
or  of  the  chrijnic  villi.  The  result  is  a  growth  of  new  connective  tissue 
and  vessels,  which  causes  a  marked  atrophy  of  the  placenta.  IMany  do 
not  admit  that  this  is  an  inflammatory  disease,  but  consider  it  a  trans- 
formation or  organization  of  blood-clots  which  have  formed  in  the 
placenta. 

What  other  morbid  conditions  may  be  found  in  the  placenta? 

Calcareous  deposits  are  sometimes  met  with.  Tliese  vary  in  size  and 
nunijjer.  Occasionally  but  a  few  small  areas  are  observed,  while  in  other 
cases  large  spots  are  formed,  covering  nearly  half  the  maternal  surfac-e. 
Fatty  degeneration,  which  occurs  in  yellowish -white  masses  niixed  with 
fibrous  tissue,  is  of  quite  frequent  occurrence.  The  effect  of  both  the 
above  ui)on  the  foetus  varies  greatly  according  to  the  extent  of  the 
change.  Some  have  thought  the  latter  to  be  simply  a  physiological 
change  occurring  at  term. 

What  alterations  in  the  shape  of  the  placenta  may  be  found? 

Though  usually  oval,  the  i)lacenta  may  be  round  or  even  croscentic  in 
shape.     Then  there  may  be  formed  one  or  several  patches  of  placental 


THE   CORD. — THE   AMNION.  60 

tissue  entirely  separated  from  the  placenta.  These  are  called  "  placentae 
succenturiatae. "  The}^  are  of  importance  onl}- from  the  fact  that  they 
may  remain  in  the  uterus  after  the  placenta  is  expressed,  and  thus  give 
rise  to  hemorrhage,  or  become  decomposed,  setting  up  a  septicaemia. 

THE   CORD. 

What  can  you  say  of  the  pathological  conditions  of  the  cord  ? 

Unusually  long  cords  are  sometimes  met  with,  but  these  give  rise  to 
no  difficulties  during  gestation,  excepting  that  they  are  more  apt  to  be- 
come knotted.  Then  also  there  is  a  greater  likelihood  of  prolapse  during 
labor.  Unnaturally  short  cords  are  also  found.  These  may  cause  a  pro- 
longed second  stage  of  labor.  Knots  of  the  cord  are  of  infrequent  occur- 
rence, and  result  from  the  child  in  its  movements  passing  through  a  loop. 
They  are  of  little  practical  importance,  as  they  are  very  rarely  tight 
enough  to  interfere  with  the  circulation,  though  cases  are  recorded  where 
the  death  of  the  foetus  has  resulted  from  a  tight  knotting. 

THE   CHORION. 

Name  and  describe  the  only  important  disease  of  the  chorion. 

Hydatiform  Degeneration  or  Vesicular  Mole. — It  is  a  disease  of  the 
chorionic  villi,  and  consists  of  a  cystic  degeneration  resulting  in  the  forma- 
tion of  small  vesicles  containing  a  clear  fluid  which  resembles  the  liquor 
amnii.  Some  believe  it  to  be  due  to  the  death  of  the  foetus,  others  sup- 
pose it  to  be  caused  by  syphilis  or  some  other  blood  disease  of  the 
mother. 

The  symptoms  are  rather  obscure,  hence  the  diagnosis  is  difficult. 
The  increase  in  the  size  of  the  uterus  is,  as  a  rule,  more  rapid  than  in  a 
normal  pregnancy,  and  no  auscultatory  signs  can  be  found,  nor  will  it  be 
possible  to  obtain  ballottement.  It  is  usually  accompanied  by  an  aqueo- 
sanguineous  discharge,  frequently  repeated,  and  perhaps  containing  small 
portions  of  the  cysts.  Upon  the  finding  of  this  does  a  positive  diagnosis 
depend. 

The  treatment  consists,  as  soon  as  the  diagnosis  is  assured,  in  imme- 
diately emptying  the  uterus.  This  may  be  done  by  the  introduction  of 
the  fingers  into  its  cavity  and  removing  the  mass,  or  by  the  use  of  a 
curette.     In  either  case  an  intra-uterine  douche  must  follow. 

THE  AMNION. 
What  is  hydramnion  ? 

Hydramnion,  or  dropsy  of  the  amnion,  is  an  excessive  amount  of 
flaid  in  the  amniotic  cavity.  This  disease  may  be  but  slightly  developed, 
in  which  case  it  gives  rise  to  few  symptoms  and  is  of  little  consequence, 
but  when  developed  to  a  marked  degree  the  symptoms  are  very  distress- 
ing, and  often  alarming.     In  many  cases  the  children  are  stillborn  or  die 


64         DISEASES   OF   THE   OVUM,    FCETUS,   AND    DECIDUA. 

soon  after  birth.  It  does  not  usually  begin  before  the  fifth  month,  and 
with  the  rapidl.y  increasing  size  of  the  abdomen  we  are  likely  to  find  all 
the  disorders  of  pregnancy  due  to  a  mechanical  cause,  such  as  dyspnoea, 
palpitation,  constipation,  etc.,  greatly  exaggerated.^ 

There  is  usually  no  difficulty  in  making  a  diagnosis.  The  foetal  extrem- 
ities are  felt  on  palpation  only  with  difficulty,  if  at  all,  and  the  heart- 
sounds  can  never  be  heard  distinctly.  The  abdomen  will^  appear  large 
and  tense,  but  the  uterine  tumor  can  be  mapped  out,  which  is  not  the 
case  when  dropsical  effusions  in  the  peritoneal  cavity  exist. 

G-enerally  the  condition  requires  no  treatment.  If,  however,  as  occa- 
sionally happens,  the  mother's  health  is  endangered,  it  will  be  necessary 
to  induce  labor.  This  should  be  done  by  puncturint;'  the  membranes.  If 
labor  has  begun,  three  dangers  arise  from  a  sudden  withdrawal  of  the 
fluid  :  (1 )  A  prolapse  of  the  funis  ;  (2)  hemorrhaue  from  sudden  detach- 
ment of  the  placenta;  (3)  syncope,  as  sometimes  hai)pensfrom  the  rapid 
withdrawal  of  fluid  from  the  bladder  or  the  peritoneal  or  pleural  cavities. 
Thus  it  is  advisable  to  elevate  the  hips,  that  the  fluid  may  pass  away 
more  slowly :  place  the  hand  tightly  against  the  vulva,  introduce  only 
the  index  finger  to  the  membranes,  that  the  force  of  the  flow  may  be 
regulated.  Use  a  small  stilette  and  rupture  membranes  during  an  inter- 
val between  the  uterine  contractions. 

THE   FCETUS. 

Are  the  eruptive  fevers  transmitted  from  the  mother  to  the 
foetus  ? 
They  all  may  be,  and,  although  the  woman  suffering  from  any  of  these 
diseases  is  likely  to  abort,  it  sometimes  happens  that  pregnancy  goes  on 
to  term.  In  these  cases  evidences  of  i\\Q  disease  may  be  found  after 
birth,  or  labor  may  come  on  when  the  period  of  viability  of  the  infant  is 
reached,  and  within  a  day  or  two  the  child  be  attacked  by  the  disease 
from  which  the  mother  is  suffering. 

From  what  inflammatory  diseases  may  a  foetus  in  utero  suffer? 

Enteritis,  pharyngitis,  laryngitis,  pleurisy,  and  i)erit()nitis  have  all  been 
observed — tlie  latter  with  more  frequency,  however.  It  may  not  be 
developed  until  term,  when  the  infant  is  Ijorn  alive  and  lives  for  some 
few  hours  or  days  suffering  from  the  disease. 

Its  cavsr^  unless  specific,  is  unknown,  but  has  been  attributed  to  blows 
on  the  abdomen,  peritonitis,  cold,  and  over-exertion  on  the  part  of  the 
mother. 

What  eruptive  diseases  besides  those  already  mentioned  (erup- 
tive fevers)  affect  the  infant  in  the  uterus  ? 
Si/phif is.— Thla  is  by  far  the  most  frefjucnt  disease  transmitted  by  the 
mother  to  the  foetus.     In  some  cases  it  cau.ses  its  death,  the  mother 
aborts,  and  in  the  child  are  found  evidences  of  syphilis,  or  the  child  may 


'     MOLES.  65 

be  born  alive,  showing  specific  taint.  In  still  another  class  of  cases  an 
apparently  healthy  infant  is  born  which  in  a  few  weeks  develops  the 
disease.  These  different  results  are  undoubtedly  due  to  the  degree  of 
severity  of  the  infection  from  which  the  mother  is  suiFering.  When 
syphilitic  children  are  born  alive,  they  are  apt  to  be  small  and  poorly 
nourished,  and  show  some  form  of  syphilide,  most  frequently  the 
pemphigoid.  If  not  found  at  birth,  it  will  almost  invariably  develop 
later.  Its  seat  is  on  the  hands  and  feet  and  about  the  arms.  From 
these  points  it  spreads  over  the  entire  body.  _ 

Malarial  Poisoning. — Children  born  in  malarial  districts  are  frequently 
found  with  enlarged  spleens,  and  cases  are  related  where  regular  parox- 
ysms occurred  in  utero,  the  frequency  varying  with  the  type  of  the 
malady. 

Lead-poisoning  and  sewer-gas  poisoning  also  afiect  the  foetus,  but  as 
a  rule  cause  abortion. 

What  injuries  may  the  foetus  meet  with  in  utero  ? 

Fractures,  either  from  falls  or  blows  received  by  the  mother  or  from 
defects  of  ossification  and  non-union  in  the  epiphj^ses.  Contusions  and 
lacerations  are  also  seen,  though  rarely.  These  are  the  result  of  injury 
sustained  by  the  mother. 

Congenital  or  Intra-uterine  Amputations. — A  child  may  be  born  with 
any  one  or  ah  of  the  four  extremities  absent.  It  is  believed  that  so- 
called  intra-uterine  amputations  are  caused  by  constrictions  of  the 
extremities  by  the  umbilical  cord  or  bands  of  false  membrane.  The 
latter  theory  is  held  by  most. 

MOLES. 

What  are  moles  ?  and  what  two  varieties  are  seen  ? 

A  mole  is  a  fleshy  mass  of  variable  size  developed  in  the  uterus  and 
receiving  its  nourishment  from  this  organ.  There  are  two  kinds — true 
and  false  moles. 

Describe  the  true  moles.* 

(1)  Hydatid  or  Vesicular  Moles  have  already  been  described. 

(2)  Ova  J/o/e.§.— These  are  merely  bhghted  ova,  and  often  become  dis- 
solved in  the  liquor  amnii  and  pass  away  surrounded  by  blood.  On 
microscopic  examination  chronic  villi  may  be  found. 

(3)  Placentcd  3Ioles.— Thin  form  is  found  most  frequently  after  abor- 
tion. A  small  portion  of  the  placenta  remains  in  utero,  which  after  a 
time  separates  and  passes  away. 

Name  the  classes  of  false  moles.f 

(1)   Sanguineous,  which  are  merely  blood-clots. 

*"  All  true  moles  are  connected  with  conception. 

t  False  moles  have  nothing  whatever  to  do  with  impregnation,  and  may  he 
found  in  virgins. 
5— Obs, 


66      ABORTION,    MISCARRIAGE,    AND    PREMATURE   LABOR. 

(2)  Fleshy  Moles. — These  consist  of  fibrin,  and  are  simply  blood-clots 
with  the  serum  and  coloring  matter  squeezed  out. 

(3)  Decidual  Moles. — These  are  masses  of  decidual  tissue. 

ABORTION,  MISCARRIAGE,  AND  PREMATURE  LABOR. 

What  is  abortion  or  miscarriage  ? 

Abortion  or  miscarriage  consists  of  the  expulsion  of  the  foetus  before 
it  is  viable.  Many  consider  the  period  of  viability  to  be  the  sixth 
month,  others  the  seventh,  so  that  by  some  any  labor  occurring  before 
the  seventh  month  would  be  called  a  miscarriage.  Up  to  the  end  of  the 
third  month  the  ovum  is  usually  expelled  entire.  After  this  time  the 
placenta  generally  comes  away  after  the  foetus. 

What  can  you  say  in  regard  to  the  frequency  of  abortion,  and  is 
it  more  common  in  primiparse  than  in  multiparas  ? 

As  an  abortion  occurring  during  the  early  weeks  is  likely  to  pass  un- 
noticed, we  do  not  really  appreciate  the  great  frequency  with  which  the 
accident  occurs.  It  has  been  said  that  90  per  cent,  of  the  married 
women  who  live  to  reach  the  menopause  have  at  some  time  or  another 
aborted.  There  is  much  discrepancy  of  opinion  in  regard  to  the  fre- 
quency at  different  periods  of  pregnancy ;  however,  the  majority  are  of 
the  opinion  that  abortion  occurs  most  frequently  between  the  second  and 
fourth  months.  It  is  much  more  common  in  multiparae,  and  is  said  to 
be  more  frequently  met  with  in  women  who  have  borne  three  or  four 
children. 

How  may  the  causes  of  abortion  be  divided  ?    Name  them. 
I.  Maternal;  II.  Paternal;  III.  Foetal. 

I.  The  maternal  causes  are — 

(1)  Artificial. — Violent  exercise,  coitus,  hfting  heavyweights,  cough- 
ing, vomiting,  blows,  falls,  compression  by  corsets,  the  use  of  a  sound, 
and  applications  to  the  cervix. 

(2)  Through  the  Blood. — Fevers  of  all  kinds,  especially  the  eruptive 
and  those  accompanied  by  high  temperature ;  syphilis,  anaemia,  poison 
of  lead,  mercury,  or  sewer-gas,  malaria,  albuminuria,  and  the  use  of 
medicines. 

(3)  Through  the  Nenous  System. — Shock,  convulsions,  over-suckling, 
and  many  nervous  disorders. 

II.  Paternal. — Syphilis  and  coitus. 

III.  Foetal. — Diseases  of  the  amnion,  chorion,  placenta,  and  cord,  and 
anything  causing  the  death  of  the  foetus;  placenta  praevia. 

What  is  the  most  frequent  cause  of  abortion  ? 

Syphilis  produces  by  far  the  greatest  number  of  miscarriages,  as  it 
may  operate  through  either  the  father  or  the  mother. 

What  can  you  say  of  the  mortality  resulting  from  miscarriages  ? 

This  depends  considerably  upon   the  causes,  also  somewhat  on  the 


ABORTION. SYMPTOMS   AND    DIAGNOSIS.  67 

period  of  pregnancy.  Dangers  arise  from  hemorrhage,  local  inflam- 
mation, and  septic  infection.  When  the  abortion  is  due  to  maternal 
causes  or  when  legitimatel}'  done,  the  mortalitj^  is  exceeding]}-  small. 
On  the  other  hand,  when  criminal!}"  done  it  is  very  great,  as  the  woman 
usually  places  herself  in  the  hands  of  an  inexperienced  physician,  and 
very  likely  keeps  on  her  feet  until  the  pains  begin.  This,  with  exposure, 
makes  the  mortality  as  high  as  50  per  cent. 

Give  the  symptoms  of  abortion  ? 

Early  abortions  resemble  very  much  a  profuse  menstruation,  and  may 
give  rise  to  no  symptoms,  or  the  patient  may  complain  of  a  sense  of  ful- 
ness about  the  thighs,  which  is  described  most  frequently  simply  as  a 
feeling  of  discomfort.  On  account  of  the  congestion  in  and  around  the 
uterus  there  will  be  a  tendency  to  frequent  micturition  or  defecation. 
The  cervix  will  be  soft  and  patulous,  and  possibly  the  os  slightly  dilated. 
When  the  accident  occurs  later  in  pregnancy,  there  are  tico  constant 
symptoms,  and  their  presence,  with  a  history  of  the  case,  makes  the 
diagnosis  easy.  These  are  _?9ai;i  and  hemorrhage.  The  latter  occurs 
first,  and  is  a  necessity  ;  the  former  is  due  to  uterine  contractions.  Oc- 
casionally these  may  be  preceded  by  a  feeling  of  malaise,  headache,  cold- 
ness of  the  extremities,  and  a  slight  rise  of  temperature,  but  these 
symptoms  are  vague  and  unreliable. 

How  would  you  make  a  diagnosis  of  a  threatened  abortion  ? 

A  history  of  the  stoppage  of  menstruation  for  only  one  period  per- 
haps, associated  with  the  early  signs  of  pregnancy,  a  hemorrhage  from 
the  uterus,  and  possibly  some  pain,  would  justify  one  in  concluding  that 
abortion  was  threatened.  After  the  diagnosis  of  pregnancy  is  certain 
the  difficulty  in  recognizing  an  impending  miscarriage  is  slight.  There 
is  a  sanguineous  discharge,  and  there  maj^  be  pain.  On  examination 
the  uterus  is  found  Ioav,  the  cervix  patulous,  the  os  is  perhaps  dilated, 
and  the  vaginal  vault  feels  tense  as  though  it  were  on  the  stretch. 

How  would  you  make  a  diagnosis  of  inevitable  abortion  ? 

Unfortunately,  the  diagnosis  of  these  cases  is  extremely  difficult — un- 
fortunately, for  when  an  impending  abortion  becomes  inevitable  the 
treatment  is  materialh"  different.  If  the  hemorrhage  be  free  and  per- 
sistent, if  there  be  considerable  pain,  and  on  examination  the  os  is  found 
dilated,  abortion  will  usuaUy  occur.  However,  in  spite  of  all  this,  there 
are  cases  where  the  hemorrhage  and  pain  have  ceased,  the  os  has  re- 
tracted, and  pregnancy  has  gone  on  to  full  term.  The  onh-  two  con- 
ditions which  can  be  said  to  render  the  abortion  almost  inevitable  are 
the  rupture  of  the  membranes  and  the  death  of  the  foetus.  Neverthe- 
less, finding  the  following  conditions  present,  we  maj^  feel  pretty  sure 
that  abortion  is  inevitable :  viz.  severe  pain,  persistent  hemorrhage,  and 
a  dilated  os. 


68      ABORTION,    MISCARRIAGE,    AND    PREMATURE   LABOR. 

How  would  you  make  a  diagnosis  of  incomplete  abortion  ? 

Ill  these  cases  we  get  a  history  of  pregnancy,  followed  by  pain,  hem- 
orrhage, and  the  passage  of  blood-clots.  Upon  careful  examination  the 
latter  are  found  to  contain  an  ovum  considerably  advanced,  but  no  pla- 
centa ;  or  perhaps  some  shreds  of  tissue  and  membrane  are  found.  The 
OS  will  be  dilated  and  the  hemorrhage  continuing.  Passing  the  finger 
into  the  cavity  of  the  uterus,  we  feel  shreds  of  membrane  adherent  to 
its  inner  surface  or  a  portion  of  the  placenta  or  perhaps  the  whole  of 
it.     If  this  is  discovered  the  diagnosis  is  made  certain. 

How  would  you  make  a  diagnosis  of  complete  abortion  ? 

When  the  abortion  has  been  complete  the  hemorrhage  ceases,  the 
uterus  contracts  firmly,  the  os  closes,  and  the  pain  ceases. 

What  is  the  treatment  of  the  different  forms  of  abortion  ? 

In  a  case  where  repeated  abortions  occur  look  for  a  cause.  If  the 
patient  be  syphilitic,  treat  this  condition  from  the  beginning  of  her 
pregnancy.     Give  her 

Red  iodide  of  mercury,  gr.  ^ ; 

Iodide  of  potash,  gr.  x. 

Sig.  T.  I.  d. 

The  iodide  of  potash  may  be  run  up  to  gr.  xx  or  3ss,  L  i  d. ,  without 
injury. 

Another  good  treatment  is  by  inunctions  of  the  oleate  of  mercury. 
Where  no  specific  cause  is  present,  but  the  abortions  occur  time  after 
time,  keep  the  patient  in  for  the  few  days  during  which  she  should 
menstruate,  and  allow  her  to  take  no  exercise  for  several  days  before 
a!i(i  succeeding  this  time.  Do  not  allow  her  to  have  intercourse  during 
the  first  four  to  six  months,  at  any  rate.  Guard  against  nervous  shock, 
extreme  physical  exercise,  or  anything  that  might  irritate  or  congest  the 
uterus.  If  a  displacement  of  the  uterus  is  present,  restore  it  to  its  nat- 
ural position,  and  keep  it  in  place  by  a  suitable  pessary  until  its  increas- 
ing size  prevents  it  again  becoming  displaced.  Diseases  of  the  uterus 
and  tubes  must  be  treated  before  imi)regnation  has  occurred. 

Two  principles  are  to  be  observed  in  the  treatment  of  all  cases  of 
threatened  aljortion,  unless  from  a  very  foul-smelling  discharge  we  know 
tiie  foetus  is  dead,  in  which  case  it  should  come  away.  These  are  abso- 
lute rest,  both  mental  and  physical,  and  the  administration  of  drugs 
which  will  allay  nervous  sensibility  and  weaken  muscular  action.  The 
first  is  obtained  by  placing  the  patient  in  bed  in  a  darkened  room ;  the 
second,  by  giving  opium,  chloral,  and  the  bromides.  Opium  may  be  ad- 
ministered hy  the  mouth,  by  the  rectum,  or  hypodermically.  A  very 
excellent  method  of  administration  is  in  the  form  of  suppositories  given 
per  rectum,  bearing  in  mind  the  fact  that  women  about  to  abort  as  a 


HEMORRHAGES  OF  PREGNANCY.  69 

rule  display  a  marked  tolerance  of  the  drug,  so  that  the  dose  must  be 
large.  With  the  opium  we  may  combine  moderate  doses  of  chloral  and 
the  bromides.  The  fluid  extract  of  viburnum  prunifolium  in  .5j  doses 
has  been  much  used  of  late,  and  with  some  good  results.  If  the  bleeding 
stops  and  pain  ceases,  you  may  feel  pretty  certain  that  the  emergency 
has  passed.  However,  the  woman  should  be  kept  in  bed  eight  or  ten 
days  longer  and  at  each  succeeding  menstrual  period.  As  soon  as  you 
feel  certain  that  no  hope  of  checking  the  abortion  remains,  the  treat- 
ment must  be  radically  altered.  The  administration  of  am^  of  the  above 
drugs  is  absolutely  contraindicated.  If  hemorrhage  is  free,  a  tampon 
must  be  immediately  introduced.  The  best  material  for  this  is  sterilized 
cotton  made  up  in  small  rolls,  and  just  before  their  insertion  immersed 
in  a  solution  of  bichloride  of  mercury,  1  :  5000.  Use  a  Sims  speculum, 
and  begin  to  pack  closely  in  the  vaginal  fornices  and  in  front  of  the  cer- 
vix. After  filling  the  whole  canal  apply  a  T-bandage.  This  jn^y  be  al- 
lowed to  remain  from  eight  to  twelve  hours,  and  upon  its  removal  the 
ovum  will  usually  be  found  to  come  away  with  it.  If  not,  give  a  douche 
of  bichloride,  and  apply  another.  If  the  hemorrhage  is  slight,  it  will 
not  be  necessary  to  use  a  tampon.  If  the  ovum  has  been  passed  and 
the  hemorrhage  continues,  place  the  woman  under  the  influence  of 
ether,  give  a  vaginal  douche,  dilate  the  cervix  if  it  be  not  already  di- 
lated, and  with  a  dull  curette  clean  out  the  entire  uterine  cavity,  after- 
ward irrigating  it  thoroughly  with  a  solution  of  carbolic  acid,  1  :  100, 
made  up  with  boiled  water.  The  after-treatment  of  abortion  is  exactly 
similar  to  that  pursued  after  a  normal  labor  at  term. 

What  is  a  premature  labor? 

It  is  the  expulsion  of  the  child  after  the  period  of  viability  is  reached, 
but  before  full  term.  Premature  labor  is  conducted,  goes  through  the 
same  stages,  and  terminates  just  as  a  labor  at  full  term,  so  that  a  further 
description  of  it  here  is  unnecessary. 

HEMORRHAGES  OF  PREGNANCY. 

What  forms  of  hemorrhage  are  met  with  during  the  first  three 
months  of  pregnancy  ? 

We  have  (1)  hemorrhage  from  the  healthy  mucous  membrane  of  the 
vagina  and  the  cervical  canal.  This  may  be  of  no  moment  unless  it 
occurs  from  the  upper  zone  of  the  cervix,  in  which  case  it  will  very  likely 
lead  to  abortion.  This  form  of  hemorrhage  usually  takes  place  during  a 
menstrual  epoch,  and  leads  the  woman  to  believe  she  is  menstruating. 
It  is  associated  with  no  pain,  and  is  due  to  a  high  arterial  tension. 

The  treatment  consists  in  lowering  the  tension  by  the  administration 
of  iodide  of  potassium  in  gr.  xx  doses,  t.  i.  cL,  saline  laxatives,  and  the 
infusion  of  digitalis. 

(2)  Hemorrhages  associated  with  ulcerations,  erosions,  and  lacerations 
of  the  cervix  date  back  before  the  pregnancy,  but  seem  to  be  aggravated 


70  HEMORRHAGES  OF  PREGNANCY. 

by  the  hyperoemia  due  to  the  pregnant  condition.  The  condition  is 
readily  recognized  by  an  examination  througli  the  speculum,  and  the 
treatment  is  purely  local,  consisting  in  the  api)lication  of  tincture  of  ido- 
dine  or  persulphate  of  iron. 

(3)  In  hemorrhage  occurring  with  primary  cancer  of  the  cervix  the 
cervix  has  an  irregular  indurated  feel  and  bleeds  freely  upon  the  intro- 
duction of  a  speculum.  There  may  also  be  a  foul-smelling  discharge. 
This  form  of  hemorrhage,  due  to  malignant  growths,  is  naturally  found 
rather  late  in  life.  If  the  woman  be  three  months  pregnant  or  less,  abor- 
tion should  be  induced.  If  further  advanced  and  the  growth  be  localized 
and  over  a  small  area,  it  may  be  removed  with  the  galvanic  cautery.  This 
is  not  likely  to  produce  abortion,  though  it  may.  When  the  disease 
seems  more  extensive  the  question  of  an  immediate  h\'sterectomy,  or 
waiting  until  the  child  is  viable  and  then  doing  laparotomy,  will  arise. 

During  the  last  six  months  two  kinds  of  hemorrhage  are  met  with  : 
(1)  accidental,  and  (2)  that  due  to  an  abnormal  implantation  of  the  pla- 
centa, or  placenta  praevia.  This  is  also  called  '"unavoidable  hemor- 
rhage. ' ' 

Define  and  give  the  causes  of  accidental  hemorrhage  ? 

An  accidental  hemorrhage  is  that  due  to  the  premature  detachment 
of  a  normally  situated  placenta.  Two  forms  are  met  with  :  in  one  the 
blood  finds  its  way  between  the  chorion  and  decidua  and  escapes  through 
the  cervix  :  this  is  called  the  open  form.  In  the  other  or  concealed  form 
the  blood  does  not  escape  through  the  os.  but  collects  within  the  uterus. 
The  separation  of  the  placenta  is,  as  a  rule,  only  partial,  and.  although 
there  is  usually  an  exciting  cause,  it  generally  occurs  in  women  whose 
constitution  has  been  undermined,  perhaps  from  some  chronic  disease. 
It  may  be  the  consequence  of  general  disease,  such  as  scarlet  fev^, 
typhoid  or  typhus  fever,  and  small-pox ;  or  of  local  disease,  as  acute  j'ellow 
atrophy  of  the  liver,  nephritis,  etc.  In  the  large  majority  of  cases  it  is 
the  result  of  undue  exertion,  blows,  falls,  strains,  liftinir  heavy  weights, 
coughing,  etc.  It  is  rarely  found  in  primipara?,  and  almost  invariably 
only  during  the  last  two  or  three  months  of  pregnancy. 

Give  the  symptoms  and  diagnosis  of  the  open  form. 

There  may  ))e  a  history  of  injury,  iullowed.  though  jierhaps  not  im- 
mediately, by  a  moderate  or  severe  hemorrhage,  and  probably  some  pain 
over  a  localized  portion  of  the  uterus.  A  vaginal  examination  reveals 
the  fact  of  a  normal  feel  to  the  cervix  and  lower  segment  of  the  uterus, 
and  also  that  this  organ  is  the  source  of  hemorrhage.  This,  with  the 
history,  makes  the  diatrnosis  easy. 

Give  the  symptoms  and  diagnosis  of  the  concealed  form. 

There  are  extreme  collapse,  exhaustion,  perhaps  syncoi)e.  ])allid  face, 
cool  or  cold  extremities,  disturbed  respiration,  and  a  small,  rapid,  and 
feeble  pulse.  Accompanying  these  there  is  excessive  pain  over  some 
portion  of  the  uterus,  and  in  some  cases  its  seat  is  marked  by  a  promi- 


ACCIDENTAL. — PLACENTA    PP.^VIA.  71 

nence  caused  by  the  accumulated  blood.  The  localized  pain  and  the 
tumor  are  apt  to  be  present  when  the  placental  detachment  has  been 
central,  and  the  margins,  still  remaining  adherent,  keep  the  blood  con- 
fined to  this  small  area.  If  the  edge  is  detached,  the  blood  flows  out 
between  the  membrane  and  uterine  wall,  causing  a  severe  pain  from  over- 
distension. Cases  are  recorded  where  the  blood  flows  into  the  foetal  sac 
through  a  rent  in  its  membranes. 

What  can  you  say  of  the  prognosis,  and  how  would  you  treat  a 
case  of  accidental  hemorrhage  ? 

When  the  blood  appears  externally  the  prognosis  is  not  very  unfavor- 
able. However,  in  the  concealed  form  it  is  very  grave.  In  all  cases  it 
is  much  worse  for  the  child  than  for  the  mother.  The  infant  mortality 
is  about  90  per  cent. ,  while  the  maternal  is  about  50  per  cent. 

Hemorrhage  from  the  uterus  can  only  cease  by  a  contraction  of  its  muscu- 
lar fibres,  thus  closing  the  orifices  of  the  open  vessels;  therefore,  im- 
mediately when  a  case  of  accidental  hemorrhage  is  seen,  whether  the  os 
be  dilated  or  not,  rupture  the  membranes  and  apply  an  abdominal  binder. 
This  latter  acts  in  two  ways :  first,  it  prevents  the  uterine  cavity  from  fill- 
ing with  blood,  and  secondly,  causes  contractions  of  the  organ  on  account 
of  the  irritation  from  its  pressure.  If*  the  hemorrhage  now  ceases,  do 
nothing  more.  Labor  will  usually  come  on  within  a  few  hours,  and 
should  be  conducted  as  an  ordinary  case  of  late  abortion.  If  the  hemor- 
rhage continues,  deliver  as  rapidly  as  possible.  When  the  cervix  is 
enough  dilated  to  allow  of  version  being  performed,  turn  and  deliver. 
If  not,  dilate  with  Barnes'  bags.  Should  the  uterus  not  contract  firmly 
after  the  birth  of  the  child,  and  should  hemorrhage  continue,  give  an 
intra-uterine  douche  of  carbolic  acid,  1  :  100,  or  bichlor.,  1  :  8000,  at  a 
temperature  of  120°  F.  Compound  tincture  of  iodine,  Bj~Oj,  may  be 
added  to  the  douche  should  the  hemorrhage  persist.  Then  full  doses  of 
ergot  must  be  given,  though  nevej-  until  the  child  is  horn.  The  collapse 
should  be  treated  by  warmth  to  the  surface,  alcohol  and  hot  water  inter- 
nally, rectal  injections  of  warm  water,  and  ether  or  alcohol  hypoderm- 
ically  if  necessary.  The  after-treatment,  as  in  all  cases  of  hemorrhage, 
consists  in  nutritious  diet,  good  hygenic  surroundings,  and  iron  internally. 

PLACENTA   PREVIA.     . 

What  is  placenta  prsevia  ? 

The  placenta  is  "  prsevia  "  when  situated  in  the  lower  segment  of  the 
uterus,  so  that  a  portion  of  it  lies  partially  over  or  completely  covers  the 
internal  os  uteri.  When  entirely  covering  the  os  it  is  said  to  be  com- 
plete or  central ;  when  only  partially  covering  the  same,  it  is  called  mar- 
ginal, partial,  or  incomplete  placenta  praevia. 

How  frequently  does  placenta  prsevia  occur?     State  the  causes. 

The  proportion  of  cases  of  placenta  prsevia  is  about  1  in  1000  or  1200 
pregnancies.     It  occurs  much  more  frequently  in  multiparae  than  prim- 


72  PLACENTA    PREVIA. 

iparse,  and  is  more  frequent  among  the  poorer  classes.  This  is  ex- 
plained by  the  fact  that  women  in  the  lower  wallcs  of  life  are  obliged  to 
get  up  too  soon  after  delivery,  leaving  the  uterus  in  a  condition  of  sub- 
involution. It  is  also  more  often  seen  in  women  who  have  borne  children 
in  rapid  succession  and  whose  uteri  remain  abnormally  large.  Thus 
the  cause  seems  to  be  a  large  uterus,  though  disease  of  the  endometrium 
and  uterine  contractions  occurring  soon  after  conception  are  also  given  as 
causes. 

Describe  the  symptoms  of  placenta  praevia.    vj>Ax^\ui>A   |*>x>  n^ 

Hemorrhage  is  the  one  important  and  characteristic  symptoms  This 
may  occur  during  pregnancy  or  not  until  labor  has  begun.  The  quantity 
of  blood  lost  may  be  but  small  at  first,  and  the  hemorrhage  is  spon- 
taneously arrested,  or  within  a  few  days  or  weeks  there  will  be  a  recur- 
rence, and  each  time,  if  the  patient  survive  the  first  loss  of  blood,  the 
quantity  is  increased.  The  blood  is  bright,  and  the  loss  is  associated 
with  all  the  general  symptoms  of  hemorrhage.  There  is  no  pain,  and 
the  flow  may,  and  usually  does,  occur  without  any  appreciable  cause.  It 
many  times  takes  place  during  what  should  have  been  the  menstrual 
period,  and  usually  not  until  after  the  sixth  month— frequently  a  few 
weeks  before,  or  even  during,  labor. 

What  is  the  immediate  cause  of  the  hemorrhage  and  the  source 
of  the  blood? 

Various  theories  have  been  advanced  to  explain  the  cause  of  the  hem- 
orrhage in  placenta  praevia.  By  some  it  is  thought  there  is  a  loss  of  pro- 
portion between  the  placenta  and  uterus,  and  necessarily  a  separation 
occurs.  This  is  said  by  some  to  be  due  to  a  more  rapid  development  of 
the  uterine  wall  than  of  the  placental  tissue  (Cazeaux),  while  others 
claim  that  the  placenta  itself  grows  more  rapidly  than  the  lower  segment 
of  the  uterus  (Barnes) ;  others,  again,  think  the  hemorrhage  due  to 
causes  which  give  rise  to  accidental  hemorrhages,  only  that  these  causes 
are  more  apt  to  operate  when  the  placenta  is  abnormally  situated  low 
down  in  the  uterine  cavity. 

The  source  of  the  hemorrhage  is  the  lacerated  uterine  vessels.  A  little 
dribbling  may  take  place  from  the  placenta  itself,  but  thrombi  soon  form 
in  the  mouths  of  these  vessels,  closing  them. 

Is  the  prognosis  favorable  in  placenta  prasvia  ?  and  would  it  ever 
be  justifiable  to  allow  a  pregnancy  to  continue  where  a  dia- 
gnosis had  been  made? 

^  The  piynnoiiis  is  very  grave  both  for  the  mother  and  child,  but  espe- 
cially so  for  the  latter.  Various  authors  estimate  the  maternal  mortality 
at  from  9  to  30  per  cent.,  and  ibr  the  child  50  to  75  per  cent.  The  evils 
to  tlie  mother  are  both  immediate  from  the  loss  of  blood,  and  subse- 
quently i'rom  septic  troubles.  The  great  liability  to  this  latter  is  due  to 
several  causes:   (1)  Infection  from  manipulations;  (2)  access  of  air  to 


DIAGNOSIS   AND    TREATMENT.  73 

tlie  uterine  sinuses;  (3)  extreme  anaemia  from  hemorrhage;  (4)  forma- 
tion of  large  thrombi,  which  decompose.  It  is  never  justifiable  to  allow 
a  pregnane}^  complicated  by  placenta  praevia  to  continue. 

How  would  you  diagnose  and  treat  a  case  of  placenta  praevia  ? 

The  diagnosis  may  be  made  first  by  the  sudden  occurrence  of  a  hem- 
orrhage from  the  uterus  with  no  apparent  cause  and  associated  with  no 
pain  or  irregular  contour  of  the  abdomen,  and  secondl}'  by  the  vaginal 
examination.  Upon  the  introduction  of  the  finger,  if  the  os  be  dilated, 
the  placenta  may  be  felt  as  a  soft,  boggy  mass  through  which  the  pre- 
senting part  is  only  indistinctly  appreciated.  This  can  be  readily  differ- 
entiated from  a  blood-clot,  which  is  readily  broken  down  by  slight  pres- 
sure of  the  examining  finger.  On  sweeping  the  finger  about  close' to  the 
uterine  wall  the  diagnosis  of  a, central  from  a  marginal  attachment  may 
be  ascertained.  If  the  cervix  is  tightly  closed,  it  will  be  found  to  have 
a  boggy,  cedematous  feel ;  a  scarcely  recognizable  presenting  part  is  found  ; 
and,  though  it  be  associated  with  difiiculty,  the  finger  can  usually  be 
pushed  through  the  os  and  the  placenta  felt. 

Treatment. — Do  not  adopt  an  expectant  plan  and  wait,  but  proceed  at 
once  to  deliver  the  woman.  Authorities  differ  on  the  subject.  3Iany 
advise,  if  the  child  be  not  viable  and  if  the  hemorrhage  be  shght,  using 
means  to  check  the  hemorrhage  and  allow  the  pregnancy  to  continue. 
These  place  the  woman  on  a  hard  bed,  apply  ice-cloths  to  the  lower  part 
of  the  abdomen,  give  acidulated  drinks,  and  keep  her  at  perfect  rest. 
This  might  be  permissible  in  a  hospital  case,  where  the  patient  is  under 
close  and  constant  observation,  but  when  not  under  these  surroundings 
it  should  never  be  considered,  for  a  hemorrhage  might  occur  at  any  time 
and  death  result  before  aid  could  be  summoned. 

When  delivery  is  decided  upon,  one  of  several  courses  may  be  adopted : 
(1)  Tamponing  the  vagina  ;  (2)  rupture  of  the  membranes;  (3)  separa- 
tion of  or  boring  through  the  placenta  and  doing  version  ;  (4)  induction 
of  labor  by  the  introduction  of  a  gum-elastic  bougie  and  by  tamponing 
the  vagina.  Each  individual  case  will  suggest  the  method  to  be  adopted" 
If  the  hemorrhage  occurs  when  labor  has  begun,  and  the  cervix  is  dilated 
sufficiently  to  allow  the  introduction  of  two  fingers  into  the  uterus,  and 
if  the  placental  attachment  be  only  marginal,  introduce  the  hand  into 
the  vagina,  pass  the  two  fingers  through  the  cervix,  push  the  edge  of 
the  placenta  to  one  side,  rupture  the  membranes,  and  by  combined 
manipulation  do  a  podalic  version.  (The  bipolar  or  Braxton-Hicks 
method  of  version  will  be  described  later.)  Pull  down  a  leg  and  allow 
the  labor  to  progress.  This  half  breech  acts  as  an  efficient  tampon,  and 
will  check  the  hemorrhage.  If  the  attachment  be  central,  push  the 
fingers  through  the  placenta  and  proceed  to  pull  down  a  leg  as  before. 
If  the  hemorrhage  occurs  before  the  os  is  dilated  or  before  it  is  dilated 
enough  to  allow  the  introduction  of  the  two  fingers,  and  if  it  be  severe, 
introduce  a  vaginal  tampon,  and  allow  it  to  remain  six  or  eight  hours ; 
then  remove.     By  this  time  the  labor-pains  will  have  begun,  and  the 


74  LABOR. 

cervix  will  usuall^y  be  sufficiently  dilated  to  allow  of  the  version  being 
performed.  If  not,  introduce  a  flexible  bougie,  and  allow  it  to  remain 
in  the  uterus  until  labor  is  well  under  way  and  the  cervix  sufficiently 
dilated  to  permit  a  version  to  be  done.  If  the  cervix  is  not  dilated,  but 
the  hemorrhage  ceases,  the  introduction  of  the  bougie  is  indicated  with- 
out tamponing,  as  this  excites  uterine  contraction. 


CHAPTER  IV. 
LABOR. 

PHENOMENA. 


Define  the  term  "labor,"  and  state  the  most  modern  theories  as 
to  its  cause. 

Labor  is  the  act  by  which  the  foetus  and  its  annexes  are  expelled  from 
the  maternal  organism.  The  causei^  are  classified  as — (1)  determining, 
and  (2)  efficient.  Among  the  determining  causes  may  be  mentioned 
fatty  degeneration  of  the  decidua  which  occurs  at  the  end  of  pregnancy. 
Through  this  degeneration  and  separation  the  nerves  over  the  interior 
of  the  uterus  become  irritated  and  excite  contraction.  Another  theory 
is  that  the  extreme  distension  of  the  uterus  causes  its  contractions  ;  still 
another  has  attributed  it  to  an  ovarian  excitement  at  a  menstrual  period; 
and  another  to  a  fatty  degeneration  in  the  placenta  and  an  accumulation 
of  carbolic  acid  in  the  sinuses.  However,  no  single  theory  has  as  yet 
been  advanced  which  is  not  open  to  many  objections. 

The  efficient  causes  are  two  :  contractions  of  the  uterus,  aided  by  con- 
tractions of  the  abdominal  muscles. 

What  is  the  character  of  the  uterine  contractions  and  the  value 
of  the  intermittent  pains  ? 

The  uterine  contractions  or  labor-pains  (for  the  words  are  used  synon- 
ymously) begin  in  the  lower  part  of  the  back,  pass  around  the  abdomen, 
and  at  times  down  the  thighs.  At  first  occurring  at  regular  but  infre- 
quent intervals,  they  gradually  become  stronger  and  more  irequent  until, 
toward  the  termination  of  labor,  but  a  very  short  interval  occurs  between 
the  contractions.  These  contractions  are  absolutely  involuntary,  but  may 
be  influenced  by  mental  impressions.  They  may  be  completely  checked 
for  a  time  or  their  j)ower  lessened  by  the  appearance  of  a  stranger  in  the 
room,  a  sudden  surprise,  or  a  disagreeable  communication.  Each  con- 
traction begins  and  gradually  increases  to  its  maximum  intensity ;  the 
uterus  becomes  tense  and  rigid,  then  relaxes,  and  the  pain  slowly  sub- 
sides.    The  contractions  are  said  to  pass  in  a  wave  from  the  lower  zone 


PHENOMENA.  75 

upward  by  a  peristaltic  action,  then  return  downward.     And  they  alter- 
nate in  severity :  first,  a  severe,  then  a  moderate  contraction. 

Nature  provides  for  the  intermittence  of  the  pains,  for  no  woman 
could  survive  an  ordinary  labor  were  the  contractions  continuous.  Nor 
could  the  child,  for  pressure  upon  it  and  the  narrowing  of  the  utero-pla- 
cental  vessels  during  a  contraction  so  interfere  with  the  circulation  that 
asphyxia  and  death  would  result  were  they  not  intermittent.  During 
the  intervals  the  patient  regains  strength  and  the  uterus  returns  to  its 
oval  shape ;  respiration  becomes  more  nearly  normal ;  the  pulse,  which 
has  been  accelerated  during  the  pain,  slows;  and  there  is  a  general  re- 
laxation of  the  whole  muscular  system. 

What  signs  or  symptoms  precede  the  beginning  of  labor  ? 

Occasionally  there  are  none,  but  as  a  rule  a  few  days  before  labor 
begins  there  is  the  so-called  "  falhng  of  the  womb."  The  inferior  seg- 
ment of  the  uterus  sinks  down  into  the  pelvic  cavity  and  the  fundus  re- 
cedes from  the  diaphragm.  The  woman  notices  that  the  waist,  which 
has  been  continually  growing  larger,  becomes  smaller,  and  respiration  is 
easier.  On  account  of  this  descent  bladder  irritability  is  apt  to  be  more 
marked,  and  a  very  frequent  desire  to  micturate  is  noticed.  (Edema  of 
the  lower  extremities  is  likely  to  be  aggravated,  and  if  hemorrhoids  be 
present  they  become  very  troublesome.  A  diarrhoea  may  occur.  A  few 
hours  before  the  uterine  contractions  begin  the  mucous  discharge  from 
the  cervix  is  more  abundant,  and  may  be  tinged  with  blood.  This  is 
called  the  ''show,"  and,  if  noticed,  is  a  pretty  sure  sign  that  labor  is 
not  far  oiF.  On  vaginal  examination  the  lower  uterine  segment  is  found 
lower  down  in  the  pelvis,  the  cervix  can  no  longer  be  felt,  and  an  ex- 
cessive mucous  secretion  is  observed. 

What  are  false  pains? 

They  are  the  pains  which  occasionally  occur  near  the  approach  of 
labor,  and  may  be  mistaken  for  true  labor-pains.  They  are  distinguished 
from  the  latter  by  the  fact  that  they  are  confined  to  some  portion  of  the 
abdomen,  are  very  irregular  in  frequency  and  severity,  and  are  not  asso- 
ciated with  a  dilatation  of  the  os,  nor  is  any  "  show  "  present. 

What  are  the  stages  of  labor  ? 

The  course  of  a  labor  from  the  time  the  first  pain  begins  until  the 
placenta  is  born  has  been  divided  into  three  stages.  The  first  begins 
with  the  true  uterine  contractions,  and  ends  when  the  cervix  is  com- 
pletely dilated.  _  The  second  begins  with  the  complete  dilatation  of  the 
OS,  and  ends  with  the  birth  of  the  child.  The  third  is  the  period  from 
the  birth  of  the  child  to  the  permanent  contraction  of  the  uterus  after 
the  delivery  of  the  placenta  and  membranes. 

What  influence  have  the  pains  of  the  different  stages  upon  the 
physical  condition  of  the  mother  ? 

The  pains  of  the  first  stage  of  labor  are  entirely  under  the  control  of 


76  LABOR. 

the  sympathetic  nervous  system,  are  involuntary,  and  therefore  cause 
little  or  no  exhaustion  of  the  vitality  unless  very  long  continued,  and 
even  then  the  exhaustion  is  owing  to  the  lack  of  sleep  and  rest  more 
than  to  the  pains.  However,  during  the  second  stage  the  cerebro-spinal 
system  comes  into  play  along  with  the  sympathetic,  and  during  each 
contraction  the  woman  strains.  Now  the  exhaustion  begins,  and  a  very 
prolonged  second  stage  may  give  rise  to  extreme  prostration. 

Describe  the  first  stage  of  labor. 

As  the  painful  uterine  contractions  commence  dilatation  of  the  cervix 
and  OS  begins.  Usually  slight  and  infrequent  in  the  beginning,  the  pains 
gradually  increase  in  severity,  frequency,  and  duration,  until,  as  the  os 
approaches  complete  dilatation,  a  very  short  period  intervenes  between 
them,  and  each  contraction  is  severe  enough  to  call  forth  a  cry  or  a  groan 
from  the  mother.  During  this  stage  the  woman  is  not  confined  to  the 
bed,  but  is  sitting  up  or  walking  about.  The  amount  of  pain  experienced 
varies  greatly  according  to  the  temperament  of  the  patient.  In  neurotic 
women  it  is  generally  very  great.  The  dilatation  may  be  accompanied 
by  nausea  and  vomiting  which  are  of  a  purely  reflex  character.  Usually 
the  secretion  becomes  more  stained  with  blood  as  the  dilatation  of  the 
external  os  progresses.  This  may  be  due  to  slight  lacerations  of  the  os 
or  to  more  serious  tears  of  the  cervix.  As  a  rule,  when  the  dilatation  is 
nearly  or  quite  complete  spontaneous  rupture  of  the  amniotic  sac  takes 
place,  and  most  of  the  liquor  amnii  drains  away.  If  a  vaginal  examina- 
tion be  made  at  the  beginning  of  labor,  the  dilatation  will  be  slight,  and 
both  orifices  of  the  cervix  may  be  appreciated,  but  as  labor  advances  the 
cervix  becomes  thinner  and  thinner  until  nothing  but  a  thin  circular  ring 
can  be  felt.  During  a  contraction  this  becomes  very  hard  and  protrud- 
ing :  through  it  can  be  felt  the  tense  hemispherical  bag  of  waters.  It 
occasionally  happens  that  the  amniotic  sac  ruptures  prior  to  or  very 
soon  after  the  beginning  of  labor.  In  this  case  the  labor  is  called  a 
"dry"  one,  and  is  usually  much  prolonged. 

Describe  the  second  stage  of  labor. 

As  soon  as  the  os  has  become  completely  dilated  and  retracts  over  the 
presenting  part  the  character  of  the  pains  alters  materially.  With  each 
uterine  contraction  the  patient  takes  a  deep  inspiration,  and  involuntarily 
grasps  with  her  hands  the  edge  of  the  bed,  the  bed-clothes,  or  the  hand 
of  some  bystander,  and,  bracing  her  feet,  strains  or  bears  down.  In  this 
way  the  abdominal  muscles  are  brought  into  play,  and  with  each  contrac- 
tion the  presenting  part  descends  into  the  pelvis.  xVs  the  head  passes 
the  ])elvic  outlet  the  vagina  dilates  and  the  perineum  begins  to  streteh. 
With  each  contraction,  which  now  becomes  stronger  and  more  frequent, 
the  tension  of  the  perineum  increases  and  the  vulvar  orifice  expands,  ex- 
posing to  view  a  part  of  the  head.  During  the  intervals  between  the 
pains  the  elasticity  of  the  i>erincal  structures  pushes  the  head  })ackward 
and  conceals  it  from  view  until  the  succeeding  contraction  of  the  uterus 


STAGES.  77 

occurs.  Owinir  to  this  recession  and  advance  the  dangers  of  laceration 
are  diminished,  as  the  parts  have  an  opi)()rtunity  to  become  thoroughly 
stretched  ;  and  this  is  carried  to  a  marked  degree,  owing  to  their  great 
dilatability.  The  urethra  is  pushed  upward ;  the  anterior  wall  of  the 
rectum  bulges,  and  if  fsecal  matter  be  present  it  is  expelled.  The  crown 
of  the  head  now  protrudes  farther,  and  does  not  recede  in  the  intervals 
between  the  pains,  and  finally,  during  the  height  of  a  contraction,  the 
head  slips  over  the  perineum.  The  shoulders  and  remainder  of  the  body 
are  soon  expressed,  and  the  birth  of  the  child  is  followed  by  a  sudden 
flow  of  amniotic  fluid  mixed  with  blood.  The  contractions  now  cease  for 
a  time,  wdien  the  third  stage  of  labor  begins. 

Describe  the  third  stage. 

It  occasionally  happens  that  immediately  the  child  is  born  the  placenta 
follows  or  is  forced  out  of  the  uterus  into  the  vagina.  However,  as  a 
rule,  the  intermittent  uterine  contractions  cease  for  a  short  time  after  the 
birth  of  the  child,  but  soon  begin  again.  The  muscular  fibres  retract  in 
all  directions,  and  the  placenta  becomes  separated  and  eventually  ex- 
pressed. The  maternal  vessels  are  naturally  torn  by  this  separation,  but, 
owing  to  firm,  tonic  contractions  of  the  walls  of  the  uterus  and  the  forma- 
tion of  coagula  in  the  mouths  of  the  vessels,  hemorrhage  is  prevented. 

What  effects  has  labor  upon  the  mother? 

The  appetite  is  lessened  or  wholly  absent.  The  secretion  of  urine  is 
increased.  The  perspiration  is  increased.  The  temperature  is  elevated. 
Mental  disturbances,  often  to  a  marked  degree  and  very  variable  in  their 
character,  are  sometimes  present. 

What  effects  has  it  upon  the  child? 

During  a  uterine  contraction  it  is  compressed,  the  placental  circulation 
is  interfered  with,  the  foetal  heart  beats  more  slowly,  and  partial  asphyxia 
results.  The  head  is  compressed  during  its  passage  through  the  pelvis, 
and  its  shape  is  altered.  Meconium  is  often  discharged  from  the  rectum, 
and  the  bladder  evacuated  during  or  immediately  following  the  birth  of 
the  body. 

What  can  you  say  in  regard  to  the  duration  of  labor  ? 

The  duration  of  labor  is  influenced  by  many  circumstances  referable 
to  both  mother  and  child.  Age,  civilization,  mode  of  living,  multiparity 
and  primiparity,  as  well  as  the  size  and  presentation  of  the  child,  deter- 
mine the  duration.  First  labors  are  almost  invariably  longer  than  sub- 
sequent ones,  and  in  old  primiparae  they  are  usually  very  prolonged. 
The  average  duration  is  said  to  be  from  twelve  to  fifteen  hours.  In 
primiparae  labor  may  be  lengthened  to  sixty  or  seventy  hours  in  excep- 
tional cases.  The  ratio  between  the  first  and  second  stages  is,  roughly 
speaking,  5  to  1. 


78  LABOR. 

PRESENTATION  AND   POSITION. 

What  is  understood  by  the  words  "presentation"   and   "posi- 
tion "  ? 

By  ' '  presentation  ' '  is  understood  the  part  of  the  child  which  offers 
itself  or  presents  at  the  superior  strait  or  inlet  of  the  pelvis.  There  are 
three  recoirnized  presentations,  all  of  which  are  subdivided  :  (1)  those 
of  the  head,  which  are  most  frequent ;  (2)  those  of  the  pelvic  extreraitj^, 
next  in  frequency ;   (3)  those  of  the  trunk,  which  are  the  least  frequent. 

By  the  term  ''position  "  is  understood  the  relation  of  the  presenting 
part  to,  certain  fixed  points  upon,  and  the  diameters  of,  the  superior 
strait  of  the  pelvis. 

Why  does  the  head  present  most  frequently  ? 

The  head  presents  in  over  90  per  cent,  of  all  cases.  Explanations  for 
this  are  numerous,  but  there  are  many  objections  to  each.  Pajot's  law 
of  accommodation  is  considered  one  of  the  best  reasons  for  the  great 
frequency  of  vertex  presentations.  It  is  this  :  "  When  one  solid  body  is 
contained  in  another,  and  if  the  latter  is  alternately  in  a  state  of  motion 
and  of  repose,  and  if  the  surfaces  are  rounded  and  smooth,  the  included 
body  constantly  tends  to  accommodate  its  shape  and  dimensions  to  the 
shape  and  capacity  of  the  containing  body." 

The  fact  that  the  centre  of  gravity  is  situated  nearer  the  head  of  the 
foetus,  tending  to  cause  this  part  to  lie  in  the  lower  segment  of  the  ute- 
rus, is  considered  by  some  the  cause.  Others  consider  the  reason  to  lie 
in  the  shai)e  of  the  uterus  and  foetal  mass.  The  large  extremities  should 
correspond,  and  if  this  is  the  case  the  head  must  lie  in  the  smallest  and 
lowest  portion  of  the  womb. 

MECHANISM  IN  VERTEX  CASES. 

How  many  positions  of  the   vertex  are  there  ?    Name  and  de- 
scribe each. 

There  are  four :  * 

(1st)  L.  0.  A.  (Fig.  11). — In  this  position  the  occiput  is  directed 
toward  the  front  and  left  side  of  the  mother;  the  sinciput  points  pos- 
teriorly and  to  the  right  sacro-iliac  joint,  and  the  long  diameter  of  the 
head  lies  in  the  right  oblique  diameter  of  the  pelvis. 

(2d)  R.  0.  A. — In  this  position  the  occiput  is  directed  toward  the  front 
and  right  side  of  the  mother,  the  sincijiut  posteriorly  and  to  the  left 
sacro-iliac  joint,  and  the  long  diameter  of  the  head  lies  in  the  left  oblique 
diameter  of  the  i)elvis  (Fiir.  12). 

(3d)  7^.  0.  /^.— Tiiis  is  exactly  the  reverse  of  the  first.  _  The  forehead 
points  to  the  left  side  of  the  mother,  the  occiput  to  the  right  sacro-iliac 
joint,  and  the  long  diameter  of  the  head  lies  in  the  right  oblique  diam- 
eter of  the  pelvis  (Fig.  13). 


MECHANISM    IN    VERTEX    CASES. 


79 


(4th)  L.  0.  P. — This  is  the  reverse  of  the  second  position.     In  it  the 
occiput  points  to  the  left  sacro-iUac  joint,  the  sinciput  to  the  right  side 


Fig.  11. 


Fig.  12. 


L.D.A. 


R.D.A. 


of  the  mother,  and  the  long  diameter  of  the  head  Hes  in  the  left  oblique 
diameter  of  the  pelvis  (Fig.  14). 


Fig.  13. 


Fig.  14. 


R.ap 


L.O.R 


Which  is  the  most  frequent  of  the  vertex  positions? 

The  first  position,  or  L.  0.  A.  About  70  per  cent,  of  all  vertex  cases 
present  in  this  position.  The  next  in  frequency  is  the  third,  then  the 
second,  and  the  least  frequent  the  fourth. 

Numerous  reasons  have  been  given  to  account  for  the  greater  frequency 
of  the  first  position,  of  which  the  most  rational  is  that  the  left  oblique 


80 


LABOR. 


diameter  of  the  pelvis  is  shorter  than  the  right, 
position  of  the  rectum. 


This  is  owing  to  the 


Describe  the  mechanism  of  delivery  in  the  first  position. 

For  convenience  of  description  the  movements  are  usually  divided  into 
stages,  though  ordinarily  these  stages  gradually  run  one  into  another,  so 
that  they  cannot  be  made  out  in  actual  practice:  (1)  period  of  flexion; 
(2)  period  of  descent  or  engagement;  (3)  period  of  internal  rotation  of 
the  head  ;  (4)  period  of  descent  and  extension ;  (5)  period  of  external 
rotation  of  the  head  and  internal  rotation  of  the  trunk;  (6)  period  of 
expulsion  of  the  trunk. 

When  labor  begins  the  occiput  is  at  the  left  ilio-pectineal  eminence, 
and  the  sinciput  at  the  right  sacro-iliac  synchondrosis.  The  back  of  the 
child  looks  forward  and  to  the  left  side  of  the  mother,  and  the  abdomen 
backward  and  to  the  right.  The  head  is  only  partially  flexed,  but  as 
soon  as  the  uterine  contractions  begin  this  flexion  becomes  more  marked, 
and  there  is  substituted  for  the  occipito-frontal  diameter  (4t  inches)  the 
suboccipito  bregmatic  (31  inches),  giving  a  gain  of  more  than  k  inch. 


Fig.  16. 


Fig.  15. 


/„,.    „  niiiiiiiiM. 


Extension  of  the  Head. 


Restitution  of  the  Head. 


The  reas(jn  of  this  flexion  is  owing  to  the  fact  that  the  vertebral  column 
is  not  articulated  in  the  centre  of  the  skull,  but  nearer  to  tlic  oc(Mj)ut, 
and,  meeting  equal  pressure  from  below,  and  the  force  from  above  being 
transmitted  through  the  vertebral  column,  the  sinciput  is  forced  upward. 
Descent  now  occurs.  The  head  becomes  engaged  in  the  pelvis,  and  from 
now  on  until  its  birth  this  movement  goes  on  continually.  The  important 
movement  of  internal  rotation  now  takes  place  by  which  the  long  diam- 


MECHANISM    IN   VERTEX    CASES.  81 

eter  of  the  head  becomes  adapted  to  the  longest  diameter  at  the  outlet 
of  the  pelvis.  This  movement  may  not  occur  until  the  head  has  reached 
the  perineum  and  is  about  to  be  born.  However,  it  usually  takes  place 
higher  up,  and  is  due  to  several  causes:  First,  according  to  Pajot's  law 
of  accommodation  (p.  78),  the  head  must  accommodate  its  diameter  to 
the  diameter  of  the  maternal  pelvis.  Secondly,  owing  to  the  direction 
of  the  inclined  planes  of  the  pelvis  the  occiput  is  directed  forward  and 
the  sinciput  backward.  Thirdly,  the  perineal  influence  after  the  head 
has  reached  this  body  may  greatly  influence  its  rotation,  if  this  be  not 
already  complete.  The  head,  having  now  reached  the  perineum,  is  born 
by  a  process  of  extension  (Fig.  15).  The  occiput  becomes  flxed  beneath 
the  symphysis  pubis  and  the  face  sweeps  over  the  perineum.  External 
rotation  of  the  head,  or  restitution,  takes  place  after  extension  (Fig.  1 6). 
The  occiput  turns  toward  the  thigh  of  the  mother,  which  correspo^ids  to 
the  side  of  the  pelvis  which  it  originally  occupied  ;  in  the  first  position, 
to  the  left  thigh.  The  shoulders  rotate,  so  that  their  long  diameter  is  in 
the  antero-posterior  diameter  of  the  pelvic  outlet,  the  anterior  or  right 
shoulder  becomes  fixed  under  the  symphysis,  and  the  left  or  posterior  is 
born  first.     The  shoulders  being  born,  the  body  immediately  follows. 

Describe  the  mechanism  of  delivery  in  the  second  position. 

In  the  second  position,  R.  0.  A.,  the  long  diameter  of  the  head  lies  in 
the  left  oblique  of  the  pelvis.  The  movements  are  exactly  the  same  as 
in  the  first  position,  excepting  that  the  rotation  takes  place  from  right  to 
left  internally  and  from  left  to  right  externally. 

Describe  the  mechanism  of  delivery  in  the  third  position. 

In  the  third  position,  R.  0.  P.,  the  occiput  is  directed  backward  and 
to  the  right  sacro-iliac  synchondrosis,  the  forehead  forward,  and  the  long 
diameter  of  the  foetal  head  lies  in  the  left  oblique  diameter  of  the  pelvis. 
The  first  movement  is  one  of  flexion.  Then  comes  descent,  which 
takes  place  more  slowly  than  in  the  anterior  positions.  Rotation  now 
occurs,  and  is  usually  prolonged  on  account  of  the  distance  througli  which 
the  occiput  must  pass.  It  rotates  from  behind  forward,  and  in  this  rota- 
tion naturally  turns  to  lie  in  the  second  position  before  it  is  completed. 
Extension,_  restitution,  and  expulsion  of  the  trunk  follow  as  in  the  pre- 
ceding position,  restitution  taking  place  so  that  the  occiput  points  to  the 
right  thigh  of  the  mother. 

Describe  the  mechanism  of  delivery  in  the  fourth  position. 

In  this  position,  L.  0.  P.,  the  occiput  points  posteriorly  to  the  left 
sacro-iliac  synchondrosis,  and  the  long  diameter  of  the  head  lies  in  the 
right  oblique  of  the  pelvis.  _  Flexion  takes  place,  then  internal  rotation 
from  left  to  right,  during  which  the  head  comes  to  lie  in  the  first  position ; 
extension,  restitution,  so  that  the  occiput  points  to  the  left  thigh  of  the 
mother,  and  expulsion  now  follows. 

In  the  third  and  fourth  positions  it  sometimes  happens  that  flexion 
6— Obs. 


82  LABOR. 

does  not  take  place  to  a  sufficient  degree,  in  which  case  descent  occurs 
without  internal  rotation.  This  being  the  condition  of*  affairs,  the  occiput 
is  born  over  the  perineum  and  the  face  under  the  symphysis,  not  by  a 
process  of  extension -as  in  the  preceding  cases,  but  by  flexion.  These 
are  extremely  difficult  and  tedious  labors,  and  will  be  spoken  of  more 
fully  later. 

What  is  the  caput  succedaneum  ?  and  how  is  it  formed  ? 

It  is  an  oedematous  tumor  of  variable  size  developed  upon  some  part 
of  the  foetal  head  during  labor.  Its  situation  varies  according  to  the 
presentation  and  position,  and  it  is  produced  by  an  effusion  from  the  ob- 
structed venous  circulation  caused  by  the  pressure  upon  the  head.  The 
swelling  occurs  on  the  uncompressed  part,  and  in  the  first  and  fourth 
positions  is  situated  upon  the  right  parietal  bone,  while  in  the  second 
and  third  it  is  upon  the  left.  In  prolonged  labors,  where  the  membranes 
have  ruptured  early,  it  is  likely  to  be  very  large,  and  may  be  entirely 
absent  in  rapid  labors. 

What  alterations  take  place  in  the  head  during  labor? 

It  is  moulded  so  that  some  of  the  diameters  are  increased,  some  de- 
creased. The  occipito-mental  and  the  occipito-frontal  are  almost  always 
diminished,  and  the  suboccipito-bregmatic  may  be.  This  moulding  is 
effected  by  the  overlapping  of  the  bones  on  account  of  their  incomplete 
ossification,  and  by  the  existence  of  the  sutures  and  fontanelles.  A  few 
days  after  birth  the  head  regains  its  normal  shape. 

ABDOMINAL  PALPATION. 
What  may  be  accomplished  by  abdominal  palpation? 

By  abdominal  palpation  we  may  discover  the  position  of  the  fundus 
of  the  uterus,  the  relative  amount  of  liquor  amnii,  the  position  and  pres- 
entation of  the  foetus,  and  in  many  cases  where  abnormalities  exist  they 
may  be  rectified  before  labor  begins. 

Describe  briefly  the  method  of  performing  palpation. 

The  woman  lies  on  her  back  on  a  hard  bed.  or  preferably  a  table,  with 
her  head  and  shoulders  slightly  elevated,  the  legs  flexed  at  the  knees  and 
the  thighs  on  the  pelvis.  The  arms  should  lie  extended  by  the  woman's 
side,  and  the  abdomen  exposed  from  the  waist  to  the  pubes.  The  ac- 
coucheur stands  on  the  right  side  of  the  patient.  His  hands  should  be 
warm,  to  prevent  reflex  abdominal  muscular  contractions. 

The  position  of  the  fundus  is  first  ascertained  by  j^lacing  the  hand  on 
the  abdomen,  immediately  above  the  symphysis,  and  carrying  it  upward. 
Over  the  uterine  tumor  marked  resistance  is  encountered,  but  this  ceases 
above  the  level  of  the  fundus.  We  then  seek  for  the  presenting  part. 
This  is  done  by  placing  the  hands  flatly  upon  the  lateral  walls  of  the  ab- 
donien  parallel  to  the  iliac  fossne,  and  slowly  depressing  them.  After 
having  determined  the  extremity  of  the  foetus  which  is  presenting,  we 


ABDOMINAL   PALPATION.  83 

seek  to  find  the  position  of  the  back  by  passing  the  hands,  one  over  the 
other,  ui3ward  on  each  side  of  the  abdominal  wall. 

How  is  a  vertex  presentation  recognized? 

By  deep  downward  pressure  in  the  iliac  fossae  a  round,  hard,  and 
usually  slightly  movable  mass  is  felt  nearly  in  the  median  line.  This  is 
the  head.  If  the  flexion  be  marked,  it  will  be  noticed  that  one  hand 
meets  with  less  resistance,  and  may  be  depressed  more  deeply,  than  the 
other.  This  will  be  upon  the  side  toward  which  the  occiput  points,  and 
is  due  to  the  ftict  that  the  opposite  hand  meets  with  the  resistance  of  the 
forehead,  which  on  account  of  the  flexion  must  rise  higher  out  of  the 
pelvis.  Passing  the  hands  upward,  if  the  position  be  either  first  or  sec- 
ond, the  smooth,  even,  resisting  surface  of  the  back  is  felt  on  the  right 
or  left  side  extending  nearly  or  quite  to  the  median  line,  while  on  the 
opposite  side  a  non-resisting  surface  is  encountered,  and  many  times 
some  of  tlie  extremities  of  the  foetus  may  be  distinctly  appreciated.  If 
the  position  be  the  third  or  fourth,  part  of  the  back  can  still  be  felt,  but 
only  a  small  area,  and  this  lying  more  to  the  right  or  left  side.  Much 
less  resistance  is  noticed  in  the  median  line  and  on  the  opposite  side,  and 
the  small  parts  are  often  distinguished  over  tlie  anterior  abdomen  wall. 
Where  the  abdominal  muscles  are  relaxed  and  palpation  made  easy,  as 
the  hands  are  passed  upward  after  encountering  the  head  they  sink  into 
a  slight  depression  or  furrow,  the  neck,  and  meet  immediately  above  this 
the  resistance  of  the  shoulder.  The  breach  generally  lies  in  the  opposite 
side  of  the  fundus,  from  which  the  occiput  points  below  and  Ibrms  a 
rounded  though  larger  and  less  resisting  mass  than  the  head.  It  may 
be  distinguished  from  the  head  by  the  absence  of  the  furrow  spoken  of 
above,  and  the  fact  that  near  it,  as  a  rule,  small  parts  may  be  felt. 

How  may  a  breech  presentation  he  recognized  by  palpation? 

On  depressing  the  hands  in  the  iliac  foss^  we  immediately  appreciate 
a  different  condition  than  when  the  head  presents.  The  mass  seems 
broader,  less  rounded,  not  so  resisting,  and,  above  all,  immovable  or 
nearly  so.  Upon  passing  upward  no  furrow  is  felt,  and  small  parts  may 
even  be  made  out  here  at  the  lower  segment  of  the  uterus.  The  back  is 
recognized  in  the  same  manner  as  in  normal  vertex  presentations.  AVe 
then  search  for  the  head  at  the  fundus.  It  almost  invariably  lies  to  one 
side  or  the  other,  and  may  be  distinctly  felt  with  its  furrow  at  the  neck, 
and  the  shoulder  lies  immediately  below.  If  there  be  a  sufficient  quan- 
tity of  liquor  amnii — in  other  words,  unless  the  amount  be  very  much 
below  the  normal— by  placing  the  fingers  over  the  head  and  by  a  quick 
movement  depressing  the  abdominal  wall,  the  head  is  pushed  away  and 
returns,  striking  the  fingers  with  an  appreciable  shock.  This  is  called 
cephalic  ballottement.  This  same  sensation  cannot  be  gotten  with  the 
breech  at  the  fundus. 

The  diagnosis^  of  the  abdominal  presentations  and  positions  by  abdom- 
inal palpation  will  be  spoken  of  farther  along,  when  these  are  taken  up. 


84  LABOR. 

DIAGNOSIS   OF   VERTEX   PRESENTATIONS. 

Where  is  the  foetal  heart  heard  most  distinctly  in  the  several 
positions  of  the  vertex  ? 
In  the  first  position  the  point  of  maximum  intensity  of  the  foetal  heart 
IS  a  small  area  situated  about  midway  betv  een  the  umbilicus  and  the  an- 
tero-superior  spine  of  the  ilium  on  the  left  side ;  in  the  second  position 
over  a  corresponding  area  on  the  right  side  ;  in  the  third  position,  though 
the  point  of  maximum  intensity  may  be  the  same  as  in  the  second,  it  is 
usually  found  farther  around  toward  the  mother\s  side.  The  same  may 
be  said  of  the  fourth  position,  except  that  it  is  farther  around  on  the 
left  side,  or  over  the  same  area  as  in  the  first  position.  In  all  vertex 
cases  the  foetal  heart  is  most  distinct  at  some  point  hdoic  a  Une  drawn 
horizontally,  so  as  to  divide  the  uterus  into  two  equal  parts. 

How  may  the  vertex  positions  he  diagnosed  by  vaginal  exami- 
nation when  labor  has  begun  and  the  cervix  is  partially 
dilated? 

By  introducing  one,  or  preferably  two,  fingers  into  the  vagina  and 
through  the  cervix,  if  the  membranes  are  ruptured,  they  come  directly 
in  contact  with  the  parietal  bones.  Now,  by  passing  backward  a  narrow 
membranous  interval  is  felt,  which  is  the  sagittal  suture.  This  should 
be  traced  by  the  fingers  to  determine  in  which  direction  it  hes.  If  it 
passes  obliquely  from  before  backward  and  from  the  left  toward  the 
right,  the  position  must  be  either  the  first  or  the  third,  but  if  it  passes 
from  right  to  left,  the  position  will  be  the  second  or  fourth. 

The  suture  is  now  followed  to  determine  the  position  of  the  posterior 
fontanelle,  and,  finding  this,  we  know  where  tne  occiput  hes.  In  the 
two  anterior  positions,  the  first  and  second,  the  posterior  fontanelle  is 
felt  anteriorly  or  nearer  the  abdomen  of  the  mother,  and  may  be  distin- 
guished from  the  fact  of  its  being  smaller,  more  triangular-shaped,  than 
the  anterior,  and  running  into  it  the  arms  of  but  three  sutures  are  found. 
These  are  the  sagittal  and  the  two  arms  of  the  lambdoid.  As  a  rule, 
unless  the  head  be  very  small,  the  anterior  fontanelle  cannot  be  felt,  as 
it  lies  too  high  up  and  too  far  posteriorly  to  be  reached.  This  is  due  to 
the  extreme  flexion.  In  the  two  posterior  positions  it  is  generally  pos- 
sible to  feel  both  fbntanelles.  owing  to  the  lack  of  marked  flexion  which 
is  usually  present  in  these  cases.  Here  it  is  necessary  to  distinguish 
between  the  two.  and  this  may  be  done  by  feeling  the  four  sutures  run- 
ning into  the  anterior  fontanelles — the  sagittal,  frontal,  and  two  arms  of 
the  coronal.  This  fontanelle  is  also  much  larger  than  the  posterior,  and 
is  diamond-shaped. 

MANAGEMENT   OF   NATURAL   LABOR. 

What  should  an  obstetrical  bag  contain? 

A  well-equipped  ob.stetrical  bag  .should  contain  a  stethoscope,  a  pair 
of  forceps,  a  set  of  hydrostatic  dilators,  a  Davidson's  syringe,  several 


PREPARATION.  85 

flexible  rubber  catheters  and  one  silver  female  catheter,  a  pair  of  scissors 
and  tape  for  tying  the  cord,  some  small  and  heavy  catgut  sutures,  several 
needles,  a  needle-holder,  two  glass  douche-nozzles,  a  rubber  douche-bag.  a 
hypodermic  syringe,  and  plenty  of  absorbent  cotton.  It  should  also  be 
provided  with  bottles  holding  chloroform  (5jv  or  5vj) ;  fluid  extract  of 
ergot;  pure  carbolic  acid,  3vj  ;  a  solution  of  the  subsulphate  of  iron, 
Jiv  ;  a  small  quantity  of  3Iagendie's  solution  of  morphine  ;  a  solution  of 
chloral  hydrate,  gr.  x  or  gr.  xv  to  the  drachm ;  a  solution  of  ergotin ; 
ether  and  brandy  for  hypodermic  use ;  and  tablets  of  corrosive  sub- 
limate. 

In  choosing  the  room  for  confinement  what  points   should  be 
observed  ? 

It  should  be  large,  well  ventilated,  well  lighted,  free  from  sewer-gas 
or  other  unwholesome  and  obnoxious  vapors.  A  room  with  a  southern 
exposure,  containing  several  windows,  is  most  desirable,  on  account  of 
the  greater  abundance  of  sunlight  it  aifords.  Always,  if  possible,  choose 
a  room  containing  an  open  fireplace,  and  have  all  unnecessary  furniture 
removed. 

What  can  you  say  in  regard  to  the  confinement  bed  ? 

Choose  a  high,  narrow  cot,  and  have  it  situated  so  that  you  may  get 
on  all  sides.  It  must  be  away  fi'om  draughts  of  air,  and  in  such  a  posi- 
tion that  good  light  is  secured.  The  mattress  should  be  firm,  smooth, 
and  free  from  all  little  irregularities.  Over  it  is  placed  a  rubber  pro- 
tector, and  upon  this  a  linen  sheet.  Under  the  woman's  buttocks  a 
second  sheet,  folded  three  or  four  times,  should  be  placed  to  absorb  the 
discharges.  The  coverings  over  the  patient  must  be  so  an-anged  that 
they  may  be  easily  adjusted  or  removed  if  necessary. 

How  should  a  patient  "be  prepared  for  her  confinement? 

If  the  bowels  have  not  been  moved  very  recently,  an  enema  of  one  or 
two  pints  of  warm  water  and  a  little  soap  should  be  given.  The  genitals 
are  then  to  be  carefully  washed  with  a  solution  of  bichloride  of  mercmy, 
and  a  warm  vaginal  douche  of  the  same  antiseptic,  in  the  strength  of 
1  :  5000  or  8000,  should  be  given.  An  entirely  clean  set  of  under- 
clothing is  to  be  put  on,  and  over  this  a  loose,  hght  wrapper. 

What  should  be  ascertained  on  the  first  visit  to  a  woman  in 
labor  ? 

First,  that  everything  is  in  readiness  for  the  birth ;  second,  that  the 
woman  has  been  properly  prepared  for  her  confinement ;  third,  the 
presentation  and  position  of  the  child,  the  general  condition  of  the 
woman,  and  the  frequency,  character,  and  strength  of  the  uteriue  eon- 
tractions  ;  fourth,  whether  or  not  the  c\iild  is  living. 


86  MANAGEMENT  OF  NATURAL  LABOR. 

How  should  the  first  examination  be  made  ? 

After  tlie  pliysician  has  carefull}'  washed  and  dried  his  hands  he 
should  palpate  and  auscult  the  patient's  abdomen,  and  after  again  re- 
cleansinir  his  hands  and  immersing  them  for  a  minute  or  more  in  a  solu- 
tion of  corrosive  sublimate,  I  :  1000,  he  should  make  a  careful  vaginal 
examination.  If  the  labor-pains  have  begun,  the  lingers  must  be  intro- 
duced during  the  interval  between  the  contractions,  and  should  not  be 
withdrawn  until  the  size  of  the  pelvis,  the  amount  of  dilatation  of  the 
OS,  and  the  presentation  of  the  child  have  been  carefully  ascertained. 
Tliis  latter  will  have  been  made  out  on  palpation,  as  will  also  the  posi- 
tion, but  the  fjrmer  may  be  confirmed  by  the  vaginal  examination.  As 
a  rule,  the  membranes  are  tense  and  bulging,  owing  to  which  tlie  exam- 
iner is  prevented  from  appreciating  the  sutures  and  fontanelles.  For 
this  examination  the  patient  should  he  upon  the  back.  Now,  if  the 
presentation  be  normal,  the  cervix  only  slightly  dilated,  and  the  patient 
a  primipara,  the  presence  of  the  physician  is  unnecessary,  and  he  may 
with  safety  leave  the  woman  for  an  liour  or  two,  but  never  unless  he  be 
within  easy  reach. 

Describe  the  management  of  the  first  stage  of  labor. 

During  this  stage  the  patient  should  not  be  confined  to  the  bed,  but 
encouraged  to  walk  about  the  room  or  recline  in  a  chair.  If  the  stage 
be  at  all  prolonged,  she  must  be  advised  to  take  food  in  moderate  quan- 
tities. Beef  tea,  broths,  milk — in  fact,  any  liijht  nourishment— should 
be  taken  at  intervals  to  prevent  exhaustion.  A'aiiinal  examinations  are 
made  only  at  infrcfiuent  intervals,  and  often  enough  for  the  attendant  to 
ascertain  the  progress  of  dilatation.  The  bladder  must  be  carefully 
watched,  and  if  it  becomes  distended  the  catheter  j^assed.  as  a  full  blad- 
der retards  the  labcjr  by  nearly  or  completely  checking  the  uterine  con- 
tractions. As  the  completion  of  this  stage  is  ai)])roached  the  pains 
become  more  freriuent  and  severe  and  their  character  changes.  Each 
contraction  is  accompanied  by  a  straining  or  bearing-down  effort,  and  as 
a  rule  the  membranes  will  rupture  spontaneously  about  this  time  and  be 
fbllinved  by  a  gush  of  fluid.  If  the  patient  has  not  3'et  lain  down,  she 
should  be  placed  upon  the  bed  and  a  vaLnnal  examination  now  made. 
If  the  cervix  is  found  to  bo  fully  dilated,  her  wrapper  must  be  removed 
and  everything  gotten  in  readiness  for  the  birth. 

How  is  the  second  stage  of  labor  to  be  managed  ? 

The  first  thing  to  ol>serve  when  the  second  or  jirupulsive  stage  has 
been  reached  is  whether  or  not  the  membranes  are  still  intact.  If  so, 
with  the  fingers  in  the  vagina  we  wait  until  a  contraction  takes  place. 
Tlu!  membranes  now  become  tense,  and  by  sinji)ly  jn'c.ssing  again.st  them 
with  the  finger-nail  they  will  usually  rupture.  If  not.  by  gently  .scratch- 
ing them  with  the  end  of  a  stylet  or  hair-pin,  thoroughly  carbolized, 
the  liquor  amnii  is  evacuated.  Hot  and  cold  water,  ice.  the  ligature, 
scissors,  and  ergot  should  now  be  in  readiness  for  use.     The  position  of 


SECOND   STAGE.  87 

the  patient  during  the  second  stage  must  be  left  to  her  selection.  In 
England  the  established  position  is  upon  the  left  side,  with  the  buttocks 
close  to  and  parallel  with  the  edge  of  the  bed,  while  upon  the  Continent 
and  in  this  country  most  obstetricians  prefer  delivering  the  woman  in 
the  dorsal  position.  If  the  choice  is  left  to  the  physician,  this  latter 
position  should  be  selected,  as  the  exposure  of  the  patient  is  less  and  the 
management  of  the  labor  much  easier  for  him.  During  the  pains  of 
this  stage  of  labor  the  patient  must  be  encouraged  to  ''bear  down"  or 
strain ;  and  this  is  greatly  facilitated  by  her  grasping  firmly  the  sides  of 
the  bed  or  a  long  towel  tied  to  its  foot.  When  the  head  has  reached 
the  perineum  these  voluntary  efforts  on  the  part  of  the  mother  should 
cease  as  far  as  possible. 

If  the  stage  be  at  all  prolonged,  it  is  advisable  that  the  physician 
auscult  the  abdomen  occasionally  to  see  if  the  foetal  heart-sounds  are 
still  distinct  and  regular.  When  the  perineum  has  become  completely 
distended,  and  just  as  the  head  is  to  pass  over  it,  the  patient  must  be 
urged  to  open  her  mouth  and  cry  out,  as  this  lessens  the  strong  force  driv- 
ing the  head  against  the  perineal  body,  and  many  times  prevents  a  tear 
which  otherwise  would  occur.  As  soon  as  the  head  is  born  the  fingers 
are  passed  down  to  the  neck  and  the  cord  felt  for.  If  it  be  found  coiled 
about  the  neck,  by  making  gentle  traction  upon  the  placental  end  it  may  be 
slipped  over  the  head,  or,  when  loosened  in  this  way,  it  may  glide  down 
over  the  shoulders  as  the  body  is  born.  It  occasionally  happens  that  it 
is  coiled  about  the  neck  two  or  three  times.  In  these  cases  it  should  be 
ligated  in  two  places  and  cut  between  the  ligatures.  If  this  becomes 
necessary,  delivery  must  be  hastened  by  pressure  upon  the  fundus  of  the 
uterus  and  gentle  traction  upon  the  child.  The  head  is  now  supported 
by  the  hand,  while  the  eyes  and  face  of  the  child  are  carefully  cleaned 
with  a  soft  wet  cloth,  and  the  nurse  or  assistant  places  a  handupon  the 
fundus  of  the  uterus  and  compresses  it  firmly  as  the  contractions  occur 
and  the  body  of  the  child  is  born.  This  hand  should  not  be  removed 
until  the  accoucheur  can  take  the  uterus  to  manage  for  the  third  stage. 
The  head  being  born  and  restitution  having  taken  place,  the  shoulders 
and  body  usually  follow  during  the  next  uterine  contraction.  If  the  con- 
tractions are  weak  and  ineffectual,  and  the  child's  life  is  endangered  by 
the  delay,  gentle  traction  may  be  made  upon  the  head  or  with  the  fin- 
gers in  the  axillae ;  but  these  measures  should  never  be  resorted  to  unless 
deemed  absolutely  necessary,  and  must  always  be  accompanied  by  a 
gentle  rubbing  of  the  fundus  of  the  uterus.  As  soon  as  the  child  is 
born  the  mouth  should  be  carefully  wiped  out,  and  after  it  has  cried  and 
the  heart-action  becomes  regular  the  cord  is  tied.  One  ligature,  prefer- 
ably of  linen  or  cotton  tape,  so  that  it  will  not  cut  through  the  cord  and 
into  the  umbilical  vessels,  is  placed  about  three  inches  from  the  umbil- 
icus, and  a  second  an  inch  nearer.  The  cord  is  then  cut  between  the 
ligatures,  and  the  end  carefully  wiped  to  see  that  no  bleeding  is  taking 
place,  if  a  large  amount  of  Wharton's  jelly  is  present,  it  is  often  ad- 
visable to  strip  the  cord.     This  hastens  desiccation,  and  may  be  done  in 


88  MANAGEMENT  OF  NATURAL  LABOR. 

the  following  manner :  After  one  ligature  has  been  applied,  the  cord  is 

f  rasped  firmly  at  the  umbilicus  between  the  thumb  and  index  finger, 
t  is  then  cut  on  the  umbilical  side  of  the  ligature,  and  with  the  fingers 
and  thumb  of  the  other  hand  the  gelatinous  matter  is  gently  squeezed 
out.     A  second  ligature  is  now  applied  near  the  end. 

Describe  the  management  of  the  third  stage  of  labor. 

As  soon  as  the  child  has  begun  breathing  naturally,  the  face  cleansed, 
and  the  cord  cut,  it  should  be  carefully  wrapped  up  in  a  soft  blanket  and 
removed  from  the  bed  to  a  warm  place.  A  towel  is  now  wrung  out  of 
some  antiseptic  solution  and  placed  over  the  vulva,  and  the  uterus  taken 
from  the  nurse  by  the  physician.  If  at  all  soft  or  relaxed,  gentle  rub- 
bing causes  the  uterus  to  contract.  Within  a  few  minutes  regular  con- 
tractions will  occur  at  short  intervals,  and  the  placenta  may  be  spon- 
taneously expressed.  If  after  waiting  fifteen  or  twenty  minutes  this  is 
not  the  case.  Credo's  method  of  expression  may  be  resorted  to.  This 
consists  in  applying  gentle  friction  over  the  fundus,  and  during  a  eon- 
traction  making  firm  downward  pressure,  with  the  fingers  extending  over 
its  posterior  and  the  thumb  its  anterior  surface. 

As  the  placenta  escapes  from  the  vulva  a  dish  is  held  in  readiness  to 
receive  it,  with  the  blood  and  clots,  and  as  it  passes  over  the  perineum 
it  should  be  taken  in  the  hand  to  prevent  dragging  on  the  membranes. 
By  making  gentle  traction  upon  the  placenta  in  a  backward  direction  the 
membranes  will  slip  out  without  tearing.  Twisting  them  into  a  rope 
during  their  withdrawal  is  not  desirable,  as  it  may  be,  and  often  is,  the 
means  of  causing  them  to  tear.  As  a  matter  of  routine  a  drachm  of  the 
fluid  extract  of  ergot  should  now  be  given,  as  it  secures  a  firm  and  per- 
sistent contraction  of  the  uterus  and  lessens  the  dangers  of  post-partum 
hemorrhage.  However,  never  give  ergot  until  the  placenta  and  mem- 
branes have  been  carefully  examined  and  found  to  be  intact. 

How  should  the  mother  now  be  cared  for? 

A  warm  douche  of  a  solution  of  bichloride  of  mercury,  1  :  5000  or 
1  :  SOOO,  is  given,  the  vulva  carefully  cleansed  with  the  same  solution, 
and,  if  the  perineum  be  lacerated,  one  or  more  sutures  ought  to  be  intro- 
duced at  once.  If  it  is  found  to  be  intact,  a  pad  is  applied  over  the 
vulva  and  the  soiled  bedding  removed.  These  vulvar  pads  may  be  made 
of  bkuiched  gauze  or  cheese-cloth  padded  with  absorbent  cotton,  and 
before  their  application  should  be  wrung  out  of  a  weak  bichloride  solu- 
tion (1  :  r)()()()).  After  keeping  the  hand  over  the  uterus  half  an  hour, 
or  longer  if  the  organ  has  any  tendency  to  relax,  the  binder  may  be 
applied.  This  is  best  made  of  coarse,  unbleached  muslin,  and  should 
extend  from  the  ensiform  cartilage  to  the  middle  of  the  thighs.  It  is 
fastened  by  pinning  down  the  centre  and  taking  gores  on  the  sides  to 
prevent  it  from  slipping  out  of  position.  Its  advantages,  when  properly 
adjusted  are  numerous  and  evident.  It  gives  a  comfortabU;  sui)p()rt  to 
the  abdominal  walls,  which  are  naturally  very  lax  after  childbirth,  and 


ANESTHESIA,   ANALGESIA.  89 

restores  the  intra-abdominal  pressure.  By  its  constant  and  even  pressure 
upon  the  uterus  it  promotes  the  invohition  of  this  organ,  which  is  so 
important  for  a  rapid  and  complete  convalescence,  and  it  prevents  relaxa- 
tion and  resulting  hemorrhage.  It  is  also  said  to  preserve  and  restore 
the  figure  of  the  patient.  If  at  the  end  of  an  hour  the  pulse  is  not  over 
90,  the  hemorrhage  is  not  free,  and  the  patient  is  resting  comfortably, 
she  may  be  left  with  safety,  but  should  be  visited  again  in  the  course  of 
six  or  eight  hours. 

What  attention  must  be  given  to  the  child  after  the  mother  has 
been  cared  for? 

Now  that  the  mother  is  attended  to,  look  at  the  child.  See  that  it  is 
breathing  naturally,  and  then  examine  the  cord  and  see  whether  or  not 
it  is  bleeding.  The  entire  body  and  scalp  of  the  infant  should  be  smeared 
with  sweet  oil  or  vaseline  to  facilitate  the  removal  of  the  vernix  caseosa, 
and  the  cord  dressed.  The  latter  maybe  done  in  this  way:  In  the  centre 
of  a  piece  of  soft  hnen  cut  a  hole  and  slip  the  cord  through,  wraj)  a  little 
absorbent  cotton  about  it,  and  fold  the  cloth  so  that  the  cord  will  be 
against  the  child's  abdomen.  _  Now  wrap  the  infant  again  in  a  soft 
blanket  and  place  it  in  a  crib  with  hot-water  bottles  or  bags  about  it,  and 
leave  it  a  few  hours  before  bathing.  At  the  end  of  six  or  eight  hours  it 
may  be  washed  in  warm  water  with  castile  soap  and  a  soft  sponge.  Do 
not  place  the  child  in  a  bath.  The  cord  after  each  bath  is  to  be  dressed 
in  the  manner  described  above,  excepting  that  it  is  well  to  dust  a  mildly 
antiseptic  powder  upon  it,  A  powder  of  1  part  of  iodoform  and  2  parts  of 
bismuth  is  efficient,  and  not  irritating.  By  this  treatment  desiccation  is 
hastened,  and  there  is  much  less  danger  of  septic  peritonitis  from  absorp- 
tion through  the  umbilicus.  After  the  bath  some  inert  powder  is  dusted 
in  the  axillae,  the  folds  about  the  neck,  and  buttocks,  and  the  child 
dressed. 

A  soft  flannel  binder  or  bellj'band  is  first  applied.  This  extends  from 
the  nipples  to  midway  between  the  umbilicus  and  symphysis,  and  must 
be  put  on  smoothly  and  loosely,  pinning  it  with  safety-pins.  Over  this 
a  soft  shirt  is  worn,  then  a  flannel  petticoat  and  a  long  dress.  The  diaper 
is  preferably  made  of  old  cotton  cloth,  it  being  soft  and  non-irritating. 
In  about  twelve  hours  the  child  should  be  put  to  the  breast  and  allowed 
to  nurse  for  five  or  six  minutes  from  each.  However,  the  mother  has 
little  or  no  milk  for  twenty-four  or  forty-eight  hours,  and  until  the  end 
of  this  time  no  regularity  need  be  observed  in  the  nm-sing. 

ANESTHESIA,  ANALGESIA. 

When  would  you  use  chloral  during  labor  ?  how  much  would  you 
give  ?  and  what  are  the  dangers  connected  with  its  adminis- 
tration ? 

Chloral  is  only  of  value  during  the  first  stage,  and  here,  when  used  in 
suitable  cases  and  properly  given,  it  is  a  drug  of  unquestionable  utility. 


90  MANAGEMENT  OF  NATURAL  LABOR. 

Where  the  pains  come  at  frequent  intervals  and  are  severe,  but  have 
httle  effect  on  the  progress  of  the  labor,  and  where  the  os  is  thin  and 
rigid  and  the  patient  nervous  and  exhausted,  cliloral  is  indicated.  It  is 
frequently  given  by  the  rectum  suspended  in  mucilage  or  milk  and  the 
yelk  of  an  egg.  A  dose  of  30  grains  may  be  given,  and  repeated  in 
three-quarters  of  an  hour  if  the  desired  effect  is  not  obtained.  By  the 
mouth  gr.  x  well  diluted  may  be  given  every  twenty  minutes  for  three 
doses,  and  after  waiting  an  hour  the  dose  may  be  once  repeated. 

The  great  danger  in  the  use  of  chloral  is  to  the  heart.  Being  a  decided 
cardiac  depressant,  it  is  absolutely  contraindicated  in  all  cases  where 
organic  affections  of  this  organ  exist. 

What  effect  has  chloral  on  a  patient  in  labor? 

It  quiets  nerv^ous  excitability,  and  produces  a  drowsiness,  if  not  sleep, 
between  the  pains.  It  lengthens  the  interval  between  the  uterine  con- 
tractions, and  makes  the  latter  stronger  and  more  regular.  Above  all, 
it  seems  to  soften  the  os  and  promote  its  dilatation. 

When  and  how  should  chloroform  be  given  during  labor? 

In  the  second  stage  only,  and,  onl.y  in  exceptional  cases,  not  until  the 
presenting  part  has  nearly  or  quite  reached  the  perineum.  A  convenient 
method  of  administration  is  to  fold  a  towel  or  napkin  six  or  eight  inches 
square,  and  n]nm  it  place  about  a  drachm  of  chloroform.  Holding  it 
with  the  first  two  fingers  on  the  moistened  surface  and  the  thumb  on 
the  oi)i)osite  side,  the  backs  of  the  former  are  allowed  to  rest  upon  the 
bridge  of  the  patient's  nose.  In  this  way  fully  90  per  cent,  of  air  is 
inhaled  with  each  inspiration,  and  no  part  of  the  towel  comes  in  contact 
with  the  face  of  the  woman.  At  the  beginning  of  a  pain  inhalation  is 
commenced,  and  should  cease  as  soon  as  the  contraction  stops.  Surgical 
anaesthesia  should  not  be  obtained  with  chloroform. 

What  are  the  dangers  arising  from  the  use  of  chloroform  ? 

It  acts  upon  the  motor  ganglia  of  the  heart,  sometimes  producing  sud- 
den death.  It  also  acts  upon  the  respiratory  centre  just  as  ether  does, 
but  to  a  less  marked  degree.  It  sometimes  excites  rather  than  quiets  the 
patient,  and  its  administration  has  to  be  stopped  on  this  account.  It 
diminishes  the  contractile  power  of  the  uterus,  and  thus  increases  the 
danger  of  hemorrhage. 

What  advantages  has  it  over  ether  as  an  anaesthetic  ? 

Jt  i.s  more  i)lea<ant  to  inhale,  and  as  a  rule  docs  not  pi'oduce  any  nausea 
or  vomiting.  Its  effects  are  much  more  (piickly  obtained,  and  are  more 
transient,  passing  away  very  soon  after  inhalation  has  ceased.  Its  vajior 
is  not  inflammable,  as  is  that  of  ether;  and  this  is  one  very  strong  ])oint 
in  its  favor,  as  most  confinements  occur  during  the  night,  when  artificial 
light  is  required.  It  is  also  true  that  pregnant  women  in  labor  do  enjoy 
a  certain,  though  not  by  any  means  absolute,  immunity  from  the  evil 
effects. of  the  anaesthetic.     The  fact  that  severe  pain  exists  gives  to  its 


THE    PERINEUM.  91 

administration  an  element  of  safety.  Furthermore,  the  woman  is  in  a 
recmnbent  position,  and  is  going  through  a  perfeetl}"  physiological 
process,  instead  of  being  run  down  by  disease,  as  surgical  patients,  to 
whom  chloroform  is  given,  often  are.  Its  slow,  gradual,  and  intermit- 
tent administration  is  a  strong  element  of  safety,  and.  above  all.  there  is 
hut  one  icell-autlie.nticated  case  of  death  on  record  ichere  chloroform  icas 
administered  by  a  practitioner  of  medicine  during  Icdjor ;  and  in  this 
case  no  autopsy  was  held. 

When  is  ether  used? 

Ether  is  by  some  practitioners  always  used  in  preference  to  chloroform 
to  allay  the  severe  suffering  during  the  pains :  however,  its  more  general 
use  is  during  operations,  when  complete  anaesthesia  is  desired. 

Two  more  drugs  have  been  used  to  some  extent  for  producing  anaes- 
thesia during  labor.  These  are  bromide  of  ethyl  and  cocaine — the  former 
by  inhalation,  the  latter  in  solution  or  ointment  as  a  local  application  to 
the  cervix,  vagina,  or  vulva.  Little  success  has  accompanied  the  use  of 
either — the  former,  on  account  of  dangers  arising  from  its  use.  and  the 
latter,  because  the  seat  of  the  pain  is  not  reached  by  local  application. 

THE   PERINEUM. 

What  are  the  causes  of  perineal  lacerations  ?   and  in  what  per- 
centage of  labors  does  laceration  occur  ? 

A  pelvis  in  which  the  subpubic  angle  is  too  acute  ;  posterior  positions 
of  the  cranium,  failing  to  rotate  ;  excessively  large  head  ;  rapid  delivery 
of  the  head  with  the  forceps,  and  failure  to  remove  the  blades  at  the 
proper  time  ;  birth  of  the  head  in  breech  labors,  where  the  delivery  must 
be  rapid  and  the  i>erineam  has  not  had  time  to  stretch:  inexperience  on 
the  part  of  the  physician. — may  all  be  causes  of  perineal  lacerations. 
Then  there  are  some  perinea  which  will  always  tear,  no  matter  how  care- 
fully the  labor  may  be  managed  and  how  favorable  the  presentation. 
This  is  observed  in  some  thick,  tense,  and  often  oedematous  perinea, 
which  seem  to  possess  no  elasticity  and  begin  to  tear  immediately  the 
head  presses  upon  them.  Occasionally  eczematous  and  and  other  skin 
affections  of  the  parts  about  the  vulva  and  rectum  render  the  tissues 
hard  and  brittle  and  favor  lacerations.  Statistics  vary  widely  as  to  the 
percentage  of  perineal  lacerations,  but  average  in  primiparae  from  18  to 
28  per  cent,  and  in  multiparte  a  little  less  than  4  per  cent.  It  is  esti- 
mated that  about  one-third  of  these  must  tear,  no  matter  how  managed. 

Describe  the  different  degrees  of  perineal  lacerations. 

(1)  Incomplete  lacerations  are  those  in  which  the  perineum  is  torn  to 
the  sphincter  ani.  Accompanying  this  external  laceration  there  is  more 
or  less  tearing  of  the  vaginal  mucous  membrane,  and  it  occasionally  ha]v 
pens  that  this  extends  up  the  posterior  vaginal  wall  nearly  to  the  fornix. 


92  MANAGEMENT  OF  NATURAL  LABOR. 

It  is  generally  confined  to  one  side  of  the  posterior  column  of  the  vagina, 
but  may  occur  on  both  sides. 

(2)  Complete  lacerations  are  those  in  which  the  perineum  is  completely 
divided,  the  sphincter  torn  apart,  and  perhaps  the  laceration  may  extend 
for  some  considerable  distance  up  the  wall  of  the  rectum.  In  these 
cases  the  vaginal  wall  is  invariably  badly  lacerated. 

Describe  the  management  of  the  perineum  after  the  head  has 
descended  upon  it. 

1st.  In  Dorsal  Deliveries. — The  objects  sought  for  are  threefold  :  First 
and  most  important,  is  to  retard  the  progress  of  the  head,  so  that  the 
perineum  may  have  time  to  become  fully  dilated  before  its  birth.  Sec- 
ond, strive  to  get  complete  flexion  of  the  head,  so  that  its  shortest  diam- 
eters may  pass  through  the  vulva.  Third,  during  its  birth  relax  the 
perineum  as  far  as  possible. 

These  are  accomplished  in  the  following  manner:  When  the  perineum 
has  begun  to  bulge  outward  during  a  contraction  of  the  uterus,  crowd 
the  chloroform.  Do  not  seek  to  obtain  anaesthesia  to  the  surgical  degree, 
but  only  sufficient  to  prevent  the  strong  expulsive  efforts  of  the  mother. 
Introduce  the  first  two  fingers  of  the  right  hand  into  the  rectum  and 
apply  the  thumb  against  the  descending  head.  With  these  two  fingers 
make  pressure  in  two  directions  on  the  frontal  region  of  the  skull — up- 
ward and  anteriorly.  The  former  increases  the  flexion  ;  the  latter  crowds 
the  occiput  forward  and  tightly  under  the  pubic  arch.  During  a  con- 
traction make  direct  pressure  upon  the  head  with  the  thumb,  to  prevent 
its  too  rapid  descent.  Then  with  the  finger  and  thumb  of  the  left  hand 
crowd  back  the  anterior  portions  of  the  labia  until  the  occipital  protu- 
berance is  felt  to  have  emerged  from  under  the  symphysis.  When  this 
has  taken  place,  wait  for  the  pain  to  subside ;  then  with  the  fingers  of 
the  right  hand  slowly  extend  the  head,  at  the  same  time  making  gentle 
pressure  downward  and  toward  the  median  line  with  the  thumb  and  two 
fingers  of  the  left  hand,  which,  being  now  at  liberty,  are  placed  near  the 
posterior  termination  of  the  labia  majora.  This  tends  to  relax  the  peri- 
neum. Do  not  allow  the  head  to  be  born  during  a  uterine  contraction 
if  it  be  possible  to  hold  it  back. 

2d.  In  the  Side  Deliveinf. — Have  the  buttocks  near  the  edge  of  the 
bed,  with  thighs  and  legs  well  flexed.  Place  a  folded  blanket  or  pillow 
between  the  knees  to  separate  them,  so  as  to  allow  room  for  manipula- 
tions with  the  left  hand,  which  is  placed  around  the  thigh  and  rests  upon 
the  child's  head.  The  other  hand  may  rest  upon  this,  and  during  a  pain 
l)ressure  with  both  is  made,  so  that  the  descent  is  as  slow  as  the  operator 
may  desire.  Chloroform  is  freely  administered  as  in  other  deliveries, 
and  the  anterior  commissure  of  the  vulva  is  crowded  back ;  but  as  ex- 
tension is  about  to  occur  the  relaxation  may  be  accom])lished  by  pushing 
the  perineum  forward  with  the  finger  and  thumb  of  the  right  hand 
placed  along  its  sides. 


EPISIOTOMY. — THE    PUERPEEAL   STATE.  93 

EPISIOTOMY. 
What  is  episiotomy? 

Episiotomj^  consists  in  making  lateral  incisions  on  each  side  of  the 
vulva  to  relieve  the  tension  and  prevent  spontaneous  lacerations  in  the 
median  line.  The  incisions  are  made  somewhat  anterior  to  the  central 
raphe,  and  should  be  made  with  blunt  scissors  during  a  uterine  contrac- 
tion. _  To  be  of  advantage  they  must  be  one-half  to  three-quarters  of  an 
inch  in  length.  After  confinement  a  suture  is  introduced  and  union 
readily  takes  place. 

Is  episiotomy  ever  indicated  ? 

It  occasionally  happens  that  a  case  is  met  with  where  laceration  seems 
unavoidable.  For  example,  before  the  perineum  has  distended  nearly 
enough  to  allow  of  the  passage  of  the  head  the  fourchette  is  seen  to  tear 
and  the  skin  covering  the  perineal  body  to  become  tense,  and  perhaps 
separate  for  a  short  distance  midway  between  the  posterior  commissure 
and  the  anus.  In  such  a  case  the  operation  is  perfectly  justifiable.  But 
it  so  rarely  happens  that  cases  are  seen  where  it  can  be  positively  asserted 
that  a  tear  must  take  place  that  this  procedure  is,  as  a  routine,  to  be  dis- 
couraged. 

Should  perineal  lacerations  be  repaired  immediately? 

They  should  in  every  instance  where  at  all  extensive.  The  internal 
lacerations  of  the  vaginal  mucous  membrane  should  be  united  by  small 
catgut  sutures,  and  for  the  deep  external  sutures  silkworm  gut,  silk,  or 
very  heavy  catgut  may  be  used.  The  former  is  preferable,  as  it  can  be 
made  sterile  so  easily  and  is  convenient  to  carry. 

THE   PUERPERAL   STATE. 

What  is  the  puerperal  state  ?    Describe  the  general  condition  of 
the  mother  at  its  beginning. 

The  puerperal  state  comprises  the  period  beginning  with  the  comple- 
tion of  the  third  stage  of  labor  and  terminating  with  the  recovery  of  the 
patient  (Hirst).  Soon  after  the  completion  of  labor  there  may  be  a  so- 
called  post-partum  chill.  This  is  usually  of  short  duration  and  of  no 
importance.  It  is  probably  nervous  in  origin  and  due  to  the  exhaustion 
following  labor.  The  pulse,  which  has  been  accelerated  during  labor, 
falls  soon  after,  many  times  considerably  below  normal,  even  to  50  or 
lower.  For  a  time  the  temperature  is  somewhat  elevated,  especially  if 
the  labor  has  been  difficult  or  prolonged.  However,  within  twenty-four 
hours  it  should  fall  to  normal  or  nearly  so,  and  remain  there  throughout 
convalescence.  There  is  a  general  feehng  of  comfort  and  well-being  and 
a  desire  to  rest,  if  not  sleep. 

Describe  the  changes  occuring  in  the   uterus  during  the   puer- 
peral state. 

Immediately  after  confinement  the  ut'^rus  is  firmly  contracted,  and 


94  MANAGEMENT  OF  NATUKAL  LABOK. 

may  be  felt  about  midway  between  the  symphysis  and  umbilicus.  As  a 
rule,  however,  it  soon  relaxes  slightly,  some  clots  come  from  within  its 
cavity,  and  twelve  or  fifteen  hours  after  the  delivery  its  fundus  lies  on  a 
level  with  or  above  the  umbilicus.  But  now  the  process  of  involution 
begins.  A  fatty  degeneration  and  absor[)tion  of  the  muscular  fibres  and 
cells  and  a  growth  of  new  cells  occur,  so  that  there  is  a  constant  loss  in 
the  weight  and  size  of  the  organ.  By  the  end  of  six  weeks  or  two 
months,  when  this  involution  is  complete,  the  uterus  weighs  but  slightly 
more  than  in  its  nulliparous  condition,  while  immediately  after  labor  its 
weight  is  about  2J  pounds.  Involution  is  promoted  by  giving,  for  a 
couple  of  weeks,  small  doses  of  ergot  (n^xv-^xx  of  the  fluid  extract, 
t.  i.  d.).  During  this  process  a  new  decidua  is  being  formed  within  its 
cavit^y.  The  superficial  layer  is  detached  and  expelled  with  the  placenta 
and  membranes,  leaving  only  fragments  behind,  which  are  adherent  to 
the  uterus.  From  these  the  new  membrane  is  formed,  and  is  complete  by 
the  fifth  week.  Large  thrombi  form  in  the  uterine  sinuses  and  gradually 
become  organized.  A  shrinking  occurs  and  a  slow  obliteration,  but  it  is 
not  until  four  or  five  months  after  labor  that  this  process  is  complete. 
The  cervix  rapidly  regains  nearly  its  normal  size,  though  never  its  virgin 
shape.  The  external  os  is  almost  hivariably  torn,  and  remains  patulous 
for  a  considerable  time. 

What  are  after-pains  ?    How  caused  and  treated  ? 

After-pains  are  simply  pains  due  to  uterine  contraction.  They  are 
caused  by  the  efforts  nature  is  making  to  decrease  the  size  of  the  uterus 
and  express  the  foreign  bodies  in  the  form  of  blood-clots  which  it  con- 
tains. They  are  almost  invariably  found  in  multiparse,  though  occa- 
sionally met  with  in  primiparae  where  the  uterus  has  been  over-distended 
by  twins  or  hydramnion.  If  care  is  taken  to  express  all  clots  and  secure 
firm  contraction  after  labor,  in  many  cases  they  will  be  avoided.  A  mix- 
ture containing 

Morphine  acetate,  gr.  i  j  ; 

Spts.  Mindererus,  3ij  ; 

Fl.  ext.  of  digitalis,  lUj, 

given  every  three  or  four  hours,  is  highly  recommended  to  relieve  them. 

Describe  the  lochia. 

It  is  a  discharge  from  the  uterus,  lasting  from  two  to  four  weeks  after 
delivery.  Abundant  at  first  and  of  a  bright-red  color,  it  gradually  de- 
creases in  amount  and  assumes  a  paler  and  eventually  a  wliite  hue.  For 
the  first  tlircc  or  four  days,  oil  account  of  the  blood  mingled  with  it,  it 
remains  red  and  is  called  "lochia  rubra."  From  this  time  until  the  eighth 
or  tenth  day  it  is  of  a  very  ])alc-red  color,  and  has  received  the  name 
"lochia  alba."     It  is  estimated  that  during  a  normal  puerperium  the 


THE   PUERPERAL   STATE.  95 

entire  lochial  discharge  amounts  to  about  3  or  3j  pounds.  A  slight  odor 
may  occasional^  be  observed  in  the  discharge,  but  if  thorough  cleanliness 
and  antisepsis  is  observed  it  never  becomes  marked. 

What  can  you  say  in  regard  to  the   care  of  the  bowels  and 
bladder  during  the  puerperium? 

From  two  causes  it  frequently  happens  that  during  the  first  few  days 
there  is  retention  of  urine.  In  some  cases  it  is  of  purely  neurotic  origin, 
and  may  be  readily  relieved  by  applying  cloths  wrung  out  of  warm  water 
over  the  suprapubic  region.  In  others  it  is  due  to  a  partial  and  tem- 
porary paralysis  of  the  neck  of  the  bladder  or  to  severe  contusions  and 
oedema  about  the  urethra  and  meatus.  In  these  cases  it  will  be  neces- 
sary to  use  the  catheter.  For  this  purpose  a  soft,  flexible  rubber  catheter 
should  be  employed,  and  the  strictest  cleanhness  and  asepsis  observed  in 
its  introduction.  It  should  be  passed  every  six  or  eight  hours,  and 
always  by  sight  and  not  by  touch. 

On  the  second  or  third  day  after  confinement  the  bowels,  if  they  have 
not  moved,  should  be  relieved  by  some  gentle  laxative.  If  the  patient 
can  take  it,  nothing  is  better  than  a  dose  of  castor  oil.  There  is  always 
a  marked  tendency  to  constipation,  which  may  be  combated  by  small 
doses  of  cascara  sagrada,  mild  mineral  waters,  laxative  pills,  or  enemas 
of  soapsuds  or  glycerin. 

What  care  should  be  given  the  breasts  during  this  period? 

Usually  in  about  forty-eight  hours  milk  is  found  in  the  breasts.  From 
this  time  on  the  child  should  be  nursed  regularly.  About  the  third  or 
fomth  day  it  frequently  happens  that  the  breasts  become  full,  tense,  and 
somewhat  painfril.  and  there  is  especial  pain  in  the  axillae :  added  to  this 
there  is  a  general  feeling  of  discomfort  and  a  slight  rise  of  temperature, 
perhaps  to  100°  or  100?°  F.  If  the  nipples  are  not  eroded  or  fissured, 
and  if  no  areas  of  induration  appear,  this  condition  need  cause  no 
anxiety.  It  is  simply  due  to  a  marked  activity  of  the  glands,  and  lasts 
only  a  day  or  two.  From  the  time  the  milk  appears  the  breasts  must  be 
properly  supported  either  by  a  binder  or  in  slings.  The  nipples  are  to 
be  carefully  washed  both  before  and  after  the  child  has  nursed.  For 
this  purpose  nothing  is  more  cleanly  than  a  solution' of  boracic  acid. 
Avoid  all  pressure  over  small  areas  of  the  breasts,  for  there  is  no  more 
easy  way .  of  setting  up  a  mastitis. 

What  should  be  the  diet  of  a  puerperal,  woman  ? 

During  the  first  twenty-four  or  forty-eight  hours  the  diet  should  con- 
sist only  of  the  most  easily  digested  articles  of  food.  3Iilk.  mutton  or 
chicken  broth,  beef  tea.  milk  toast,  and  a  little  bread  may  be  allowed. 
The  patient  should  receive  some  nourishment  every  three  or  four  hours 
if  awake.      After  the  second  day  any  digestible  foods  may  be  given. 


96  MANAGEMENT  OF  NATURAL  LABOR. 

Avoid  all  pastry,  cakes,  fresh  vegetables,  ricli  desserts,  fruits,  and  sweets 
while  in  bed.  At  the  end  of  a  couple  of  weeks  she  may  resume  her 
usual  diet,  taking  care  only  to  avoid  such  food  as  would  be  likely  to  cause 
indigestion. 

How  frequently  should  the   vulvar  dressing  be   changed?  and 
when  may  a  post-partum  woman  be  allowed  to  sit  up  ? 

During  the  first  twenty-four  or  forty-eight  hours  the  lochial  discharge 
is  rather  profuse,  so  that  every  three  or  four  hours  a  clean  new  dressing 
ought  to  be  applied,  taking  care  to  carefully  cleanse  the  vulva  and  sur- 
rounding parts  with  a  warm  solution  of  bichloride  of  mercury,  1  :  5000. 
After  this,  and  up  to  the  eighth  or  tenth  day,  four  times  in  the  twenty- 
four  hours  is  quite  sufficient.  From  day  to  day,  by  examining  the  abdo- 
men, the  size  of  the  uterus  can  be  appreciated.  Until  the  fundus  has 
disappeared  below  the  symphysis,  or  at  least  can  be  felt  on  a  level  with 
the  pubis,  the  patient  should  be  kept  in  bed. 

How  may  a  diagnosis  of  the  puerperal  state  be  made  ? 

By  the  size  of  the  breasts  and  presence  in  them  of  milk  or  colostrum ; 
by  the  flabby,  wrinkled  condition  of  the  abdominal  walls  and  the  large 
size  of  the  uterus ;  by  the  open  and  perhaps  lacerated  cervix  ;  the  cha- 
racter and  amount  of  the  lochial  discharge  ;  the  large  and  relaxed  vagina 
and  abrasions  about  the  vulva,  or  perhaps  perineal  laceration. 

CARE   OF  THE  INFANT. 

Describe  the  care  of  the  infant  the  first  twenty-four  hours  of  its 
existence. 

For  a  few  hours  keep  it  well  wrapped  up  in  blankets  and  warm.  Then 
bathe  and  dress  it,  and  allow  it  to  nurse  for  a  few  minutes  from  each 
breast.  After  this,  if  it  cries  and  worries,  it  may  be  given  a  little  warm 
water  or  warm  peppermint-water  with  a  medicine-dropper.  It  should 
not  be  allowed  to  nurse,  as  it  only  worries  the  mother  and  the  child  gets 
no  nourishment. 

How  frequently  should  it  be  allowed  to  nurse   after  the  first 
day? 

Every  two  or  two  and  a  half  hours,  beginning  at  seven  in  the  morning 
when  the  mother  awakens,  and  continuing  until  nine  in  the  evening. 
During  the  night,  if  restless  or  wakeful,  it  may  be  allowed  to  nurse  once 
or  twice.  Above  all,  observe  regularity  in  its  feeding,  and  even  though 
the  child  be  asleep  it  should  be  awakened  when  the  hour  for  its  nursing 
comes  around.  Always  keep  it  loosely  though  warmly  clad,  and  in  such 
a  position  that  bright  light  does  not  strike  the  eyes. 


UNNATURAL   LABOES.  97 

CHAPTER   V. 
UNNATURAL  LABORS. 

PERSISTENT   OOCIPITO-POSTERIOR  POSITIONS. 

State  the  causes  which  may  operate  to  prevent  anterior  rotation 
of  the  occiput  in  posterior  positions  of  the  vertex. 

Incoinplete  flexion  of  the  head,  so  that  the  chin  does  not  come  in  con- 
tact with  the  sternum,  an  excessively  large  head,  or  a  normal  head  and 
a  justo-minor  pelvis,  and  a  very  small  head  and  roomy  pelvis.  (The  last 
class  of  cases  is  usually  seen  in  premature  labors,  and  as  a  rule,  though 
rotation  does  not  occur,  the  labor  is  no  more  difficult  than  it  would  be 
were  the  occiput  anterior.) 

Describe  the  management  in  this  class  of  cases. 

If  complete  flexion  can  be  secured,  these  cases  will  usually  rotate,  so 
our  one  object  in  their  management  is  to  promote  flexion  by  upward 
pressure  on  the  sinciput  during  uterine  contractions.  At  the  same  time 
an  attempt  may  be  made  to  aid  rotation  of  the  forehead  backward  by 
pressing  in  that  direction  on  the  side  which  looks  toward  the  pubes. 
Many  cases  of  this  kind  occur  where  the  rotation  takes  place  very  late 
in  the  labor,  and  not  until  the  head  is  well  down  upon  or  bulging  the 
perineum.  If  the  labor  is  much  prolonged,  the  energies  of  the  mother 
are  becoming  exhausted,  and  no  rotation  or  descent  is  taking  place,  the 
forceps  should  be  applied  and  the  head  drawn  down  to  the  perineum. 
The  blades  should  then  be  removed,  and  labor  allowed  to  terminate  by 
the  natural  forces.  Usually  at  this  time  rotation  occurs,  and  the  case  is 
practically  the  same  as  an  anterior  position.  If  the  occiput  is  born  pos- 
teriorly, the  perineum  is  invariably  badly  lacerated. 

FACE  PRESENTATIONS. 

Give  the  frequency  and  cause  of  face  presentations. 

The  frequency  of  presentation  of  the  face  varies,  according  to  different 
authors,  from  1  in  150  to  1  in  450  labors,  the  average  being  about  1  to 
200.  The  transformation  from  vertex  to  face  usually  takes  place  during 
the  last  few  weeks  of  pregnancy,  and  may  be  due  to  one  of  a  number  of 
difl"erent  causes.  Uterine  obliquity  (marked) :  doHcho-cephalic  child  ; 
tumors  of  the  neck  and  thorax ;  excessive  amount  of  liquor  amnii  and 
a  small  child  ;  ^  rapid  evacuation  of  the  liquor  amnii  during  labor ;  hitch- 
ing of  the  occiput  at  the  brim  of  the  pelvis,  and  a  lack  of  proper  flexion 
as  the  head  enters  the  pehds, — have  all  been  given  as  causes. 

Name  the  positions  of  the  face. 

The  first  podtion  corresponds  to  the  first  position  of  the  vertex.     In 
7— Obs. 


98 


UNNATURAL   LABORS. 


it  the  chin  points  to  the  right  sacro-ihac  sjmiphysis  and  the  forehead 
anteriorly  and  to  the  left— K.  M.  P.  (right  mento-posterior,  Fig.  17). 


Fig.  17. 


Fig.  18. 


RM.R 


L.M-R 


The  second  position  corresponds  to  the  second  vertex  position.  The 
chin  points  to  the  left  sacro-iliac  symphysis,  the  forehead  anteriorly  and 
to  the  right — L.  M.  P.  (left  mento-posterior,  Fig.  18).       _ 

The  third  position  corresponds  to  the  third  vertex  position.     In  it  the 


Fig.  19. 


Fig.  20. 


L.M.A. 


R.M.A, 


chin  is  directed  anteriorly  and  to  the  left  side,  the  forehead  posteriorly 
and  to  the  right  sacro-iliac  symphysis— L.  M.  A.   (left  mento-anterior, 

The  fourth  position  corresponds  to  the  fourth  vertex  position.     The 


FACE    PRESENTATIONS.  99 

chin  is  directed  anteriorly  and  toward  the  riiiht  side  of  the  mother,  the 
forehead  posteriorly  and  to  the  left  sacro-iliac  symphysis — R.  M.  A. 
(right  mento-anterior,  Fig.  20). 

How  would  you  diagnose  a  face  presentation  before  the  mem- 
branes have  ruptured? 

It  is  often  extremely  difficult  to  make  a  diagnosis  before  this  time.  Pal- 
pation in  the  first  two  positions  may  lead  us  to  suspect  a  face,  but  by  it  a 
positive  diagnosis  cannot  be  made.  After  feeling  the  head,  the  hands, 
being  passed  over  the  abdomen  and  considerable  pressure  made,  suddenly 
sink  into  the  deep  sulcus  lying  between  the  occiput  and  shoulders.  On 
vaginal  examination  the  membranes  during  a  pain  are  more  prominent 
and  project  farther  through  the  cervix.  The  hard  forehead  is  felt,  and 
when  the  membranes  are  relaxed  it  is  at  times  possible  to  appreciate  the 
nose  and  orbital  cavities. 

How  would  you  diagnose  a  face  presentation  after  rupture  of 
the  membranes  ? 

The  only  time  a  mistake  can  now  be  made  in  the  diagnosis  is  when  the 
labor  has  been  prolonged.  Under  these  circumstances  the  face  becomes 
very  much  swollen  and  oedematous,  and  no  landmarks  can  be  appreciated. 
Ordinarily,  the  forehead  is  felt  with  the  frontal,  and  perhaps  the  coronal, 
sutures.  Then  by  passing  the  fingers  down  the  frontal  suture,  the  root 
of  the  nose,  the  orbits,  the  superciliary  ridges,  the  nostrils,  and  the 
mouth  may  all  be  easily  recognized.  By  putting  the  finger  into  the 
mouth  the  alveolar  ridges  prove  conclusively  the  presentation,  and 
make  the  differentiation  from  a  breech  possible.  Extreme  care  must 
be  observed  not  to  press  roughly  against  the  face  and  thus  injure  the 
features. 

Give  the  mechanism  in  face  presentation. 

In  face  presentation  the  mechanism  of  delivery  is  nearly  the  same  as 
in  the  vertex,  only  that  we  must  consider  the  forehead  in  face  to  take 
the  place  of  the  occiput  in  vertpx  presentations.  Thus  we  have,  as  in 
vertex  cases,  five  periods,  constituting  the  mechanism:  1st,  extension; 
2d,  descent  and  engagement;  3d,  internal  rotation;  4th,  descent  and 
flexion ;  5th,  restitution  and  external  rotation. 

By  the  first  movement,  or  that  of  extension,  the  occiput  is  pressed 
backward  and  the  chin  descends  lower  in  the  pelvis  than  the  forehead. 
In  this  position  engagement  occurs  and  descent  begins.  It  is  now  that 
the  rotation  takes  place  just  as  in  vertex  cases,  and  for  exactly  the  same 
reasons.  By  the  time  the  process  is  completed  the  face  has  reached  the 
floor  of  the  pelvis,  with  the  chin  anterior  and  the  occiput  lying  in  the 
hollow  of  the  sacrum.  Then  begins  the  fourth  movement,  or  that  of 
flexion.  The  chin  emerges  under  the  pubic  arch,  and  there  becomes 
fixed,  allowing  the  forehead,  face,  and  occiput  to  successively  sweep  over 


100  tnSTNATURAL   LABORS. 

the  perineum.  The  last  movement  of  restitution  now  occurs,  exactlj'^  as 
in  normal  vertex  positions,  and  the  mechanism  for  the  shoulders  and 
body  is  just  the  same  as  in  vertex  cases. 

Does  the  face  always  rotate  anteriorly? 

It  does  not,  and  in  such  cases,  if  the  labor  be  at  term,  the  child  of 
normal  size,  and  the  pelvis  not  unusuall}'^  large,  operative  interference 
of  some  kind  is  invariably"  necessar3^  In  these  cases,  which,  fortunatelj'', 
are  extremely  rare,  the  crown  of  the  head  is  jammed  tightly  behind  the 
pubes  and  the  chin  lies  in  the  hollow  of  the  sacrum.  This  places  the 
long  occipito-mental  diameter  in  relation  with  the  antero-posterior  diam- 
eter of  the  pelvic  outlet ;  and,  bearing  in  mind  the  fact  that  the  latter  is 
but  5  inches,  while  the  former  is  5}  inches,  and  that  little  or  no  shorten- 
ing of  this  diameter  can  occur,  it  will  be  readily  seen  how  impossible 
delivery  is  unless  the  head  is  compressed. 

What  can  you  say  of  the  prognosis  and  treatment  of  face  pres- 
entations ? 

The  dangers  to  the  child  are  much  greater  than  in  vertex  cases,  even 
though  internal  rotation  occurs.  The  labor  is  apt  to  be  prolonged,  and 
the  child  is  subjected  to  an  extreme  amount  of  pressure,  which  many 
times  causes  cerebral  congestion  or  hemon-hage ;  so  that  the  mortality, 
when  anterior  rotation  of  the  chin  occurs,  is  between  8  and  14  per  cent. 
When  this  does  not  occur,  it  is  almost  100  per  cent,,  as  most  of  these 
cases  require  craniotomy.  To  the  mother  the  prognosis  is  but  slightly 
graver  than  in  vertex  cases. 

Treatment. — Various  methods  of  treatment  have  been  adopted  in  face 
presentations,  which  in  some  instances  have  met  with  success,  in  others 
failure,  so  that  few  authors  attempt  to  lay  down  any  fixed  rules  by  which 
all  cases  should  be  treated. 

If  the  diagnosis  is  made  before  the  cervix  is  completely  dilated  and 
before  the  presenting  part  has  entered  the  pelvis,  we  may  resort  to 
one  of  two  procedures — convert  it  into  a  vertex  or  do  a  podalic  version. 
(Unless  the  chin  lie  anteriorly,  in  which  case,  if  we  fail  in  changing  to 
a  vertex,  the  lahor  should  he  left  to  nature.) 

A  very  clear  and  concise  description  of  the  former  treatment  has  been 
given  by  Dr.  Partridge  in  a  paper  read  before  the  New  York  State  Med- 
ical Society  a  few  years  ago.  In  it  he  says:  "The  conditions  especially 
favorable  to  the  operation  are  an  os  nearly  or  quite  dilated ;  a  face  not 
engaged  in,  or  at  least  capable  of  being  readily  lifted  from,  the  pelvic 
brim  ;  an  unruptured  bag  of  waters ;  a  capacious  vagina.  In  a  majority 
of  labors  a  stage  is  reached  when  there  are  present  these  conditions." 
His  method  of  procedure  is  to  "give  chloroform  for  relaxing  the  struc- 
tures of  the  parturient  canal,  to  quiet  the  movements  of  the  patient,  and 
to  obviate  pain."  The  hand  is  then  introduced  into  the  vagina,  and  the 
fingers  passed  up  through  the  cervix  into  the  uterus.  The  palms  are  pas.sed 
over  the  occiput  and  traction  made  in  a  downward  direction,     "llexion 


PELVIC   PRESENTATIONS.  101 

may  be  greatly  aided  by  external  manipulation."  Continuing,  he  says 
that  ' '  in  some  instances  in  which  the  membranes  are  unruptured  at  the 
beginning  of  the  operation  they  remain  unbroken  at  its  comj^letion, 
"showing  how  simple  the  operation  can  be."  After  flexion  has  been  ob- 
tained the  case  must  be  carefully  watched,  and  any  tendency  to  a  return 
to  the  face  presentation  should  be  checked  by  applying  the  forceps  and 
engaging  the  head.  Version,  then,  is  never  justifiable  when  the  above 
can  be  done,  and  should  only  be  resorted  to  after  all  attempts  to  engage 
the  head  in  a  flexed  position  have  failed,  and  then  onhj  when  the  cldn 
points  posteriorly.  If  the  case  is  not  seen  until  the  face  has  entered  the 
pelvis,  but  one  plan  of  treatment  offers  itself — namely,  that  which  will 
secure  anterior  rotation  of  the  chin  if  possible.  This  will  almost  always 
take  place  if  marked  extension  be  present ;  therefore  we  should  aid  this 
by  upward  pressure  with  two  fingers  on  the  forehead  during  each  uterine 
contraction.  If  this  prove  unsuccessful,  an  attempt  may  be  made  to 
secure  rotation  by  placing  the  fingers  in  the  mouth  and  drawing  the  chin 
forward  during  a  pain. 

xlnother  method  of  accomplishing  the  same  result  has  proven  success- 
ful in  the  hands  of  some  accoucheurs.  This  consists  in  introducing  one 
blade  of  the  forceps  so  as  to  press  upon  the  posterior  cheek.  All  three 
methods  may  be  attempted.  If  failure  is  encountered,  and  the  chin 
continues  to  point  posteriorly,  the  only  resource  left  is  to  perform  crani- 
otomy. 

PELVIC  PRESENTATIONS. 

How  are  breech  presentations  divided? 

Into  complete  or  full  and  incomplete.  In  the  first  variety  the  thighs 
are  flexed  upon  the  pelvis,  the  legs  upon  the  thighs,  the  feet  are  crossed, 
and  are  in  contact  with  the  buttocks.  There  are  several  varieties  of  in- 
complete breech  presentations :  (1 )  Those  in  which  the  thighs  are  flexed 
on  the  pelvis,  but  the  legs  are  extended  at  the  knee,  so  that  the  feet  lie 
by  the  child's  face  and  the  buttocks  alone  present.  (2)  Cases  are  met 
with  where  the  thighs  are  but  slightly  flexed  and  the  legs  completely  so. 
These  constitute  knee  presentations.  (3)  The  lower  limbs  are  completely 
extended  :  these  are  the  so-called  footling  presentations.  (4)  Very  rarely 
it  happens  that  one  leg  is  flexed,  the  other  remaining  completely  ex- 
tended. The  mechanism  is  exactly  the  same,  no  matter  how  the  pelvic 
extremity  presents. 

State  the  frequency  and  causes  of  pelvic  presentations. 

At  full  term  about  1  labor  out  of  every  60  is  breech.  In  premature 
labors  pelvic  presentations  are  much  more  freciuent,  averaging  nearly  1 
in  20  labors. 

One  of  the  most  frequent  causes  of  pelvic  presentations  is  premature 
delivery.     Among  other  causes  may  be  mentioned  an  excessive  amount 


102 


UNNATURAL   LABORS. 


of  liquor  amnii,  a  verj^  large  uterus,  a  small  child,  a  hj^drocephalic  child, 
placenta  pr^evia.  and  all  forms  of  pelvic  deformities. 

How  many  positions  are  met  with  in  pelvic  presentations? 

Four. 

1st.  Left  Sacro-anterior   (L.  S.  A.).— The  back  of  the  child  points 


Fig.  21. 


Fig.  22. 


L.S.A. 


RS.A. 


anteriorly  and  to  the  left  side  of  the  mother,  and  the  long  diameter  of 
the  hips  lies  in  the  left  oblique  of  the  pelvis  (Fig.  21). 


Fig.  23. 


Fig.  24. 


RS.P 


L.S.R 


2d.  Right  Sacro-anterior  (R.  S.  A.).— The  dorsum  of  the  child 
points  anteriorly  and  to  the  right  side  of  the  mother,  and  the  long  diam- 
eter of  the  hips  lies  in  the  right  obliciue  of  the  pelvis  (Fig.  22). 


PELVIC   PRESENTATIONS.  103 

3d.  Right  Sacro-posterior  (R.  S.  P.). — In  this  position  the  back 
of  the  child  points  posteriorly  and  to  the  right  side  of  the  mother, 
and  the  long  diameter  of  the  hips  lies  in  the  right  oblique  of  the 
pelvis  (Fig.  23). 

4th.^  Left  Sacro-posterior  (L.  S.  P.). — The  back  of  the  child  points 
posteriorly  and  to  the  left  side  of  the  mother,  and  the  long  diameter  of 
the  hips  lies  in  the  left  oblique  of  the  pelvis  (Fig.  24). 

Describe  the  mechanism  of  delivery  in  the  four  pelvic  presenta- 
tions. 

Unless  the  pelvis  be  normal  and  the  child  at  full  term,  there  will  be 
no  mechanisni  in  pelvic  presentations.  In  the  first  position  we  have  first 
a  moulding  of  the  breech,  occurring  with  the  descent.  This  is  really  an 
act  of  adaptation.  Now,  after  engagement  has  taken  place,  internal  rota- 
tion of  the  trunk  begins.  This  is  due  to  exactly  the  same  causes  as  in 
vertex  presentations,  and  when  completed  the  left  hip  lies  under  the 
symphysis  pubis  and  the  long  diameter  of  the  buttocks  is  in  conformity 
with  the  antero-posterior  diameter  of  the  outlet  of  the  pelvis.  The  next 
movement  is  one  of  lateral  flexion.  By  this  the  posterior  (right  buttock) 
is  born  oyer  the  perineum ;  then,  the  descent  continuing,  the  left  but- 
tock is  disengaged  from  under  the  symphysis,  and  the  limbs,  trunk, 
elbows,  and  shoulders  are  born  in  succession.  External  rotation  of  the 
trunk  and  internal  rotation  of  the  head  take  place  as  the  body  is  ex- 
pressed, and  if  complete  flexion  of  the  head  has  been  maintained,  by 
the  time  the  trunk  is  born  the  occiput  has  rotated  from  left  to  right  and 
Hes  under  the  sjauphysis  pubis.  Here  it  remains  fixed,  and  in  succession 
the  following  diameters  appear:  the  occipito-mental  the  suboccipito- 
frontal,  and  the  suboccipito-bregmatic.     Last  of  all,  the  occiput  is  born. 

In  the  second  position  the  movements  are  exactly  the  same,  excepting 
that  they  take  place  in  opposite  directions.  The  internal  rotation  brings 
the  right  hip  under  the  symphysis,  and  the  occiput  rotates  from  right  to 
left,  instead  of  from  left  to  right. 

In  the  third  position  the  mechanism  is  the  same,  only  the  rotation 
must  be  more  extensive  to  bring  the  right  hip  under  the  symphysis.  So 
also  must  be  the  rotation  of  the  occiput,  and  this  takes  place  just  as  in 
the  third  vertex  position. 

From  the  foregoing  the  mechanism  of  the  fourth  pelvic  position  will 
be  readily  understood. 

What  are  the  causes  of  infant  mortality  in  pelvic  presentations  ? 

1st.  Compression  of  the  Cord. — This  may  occur  to  a  serious  degree 
even  before  the  head  has  reached  the  pelvic  brim,  which  is  the  time  at 
which  funic  compression  is  usually  considered  dangerous.  The  cord  is 
caught  between  the  trunk  of  the  child  and  the  wall  of  the  pelvis.  Even 
though  this  does  not  happen  as  soon  as  the  head  enters  the  superior 
strait,  the  foetal  circulation  through  the  cord  is  interfered  with,  if  not 
stopped  entirely. 


104  UNNATURAL   LABORS. 

2d.  Extension  of  the  Head. — This  a  grave  complication,  as  delivery  of 
an  extended  head  is  invariably  retarded — often  until  death  of  the  foetus 
occurs. 

3d.  Extension  of  the  Arms. — This  also  causes  delay  just  at  the  point 
when  rapid  delivery  is  necessary. 

4th.  Inspiratory  Efforts  before  the  Birth  of  the  Head. — ^By  these 
mucus,  blood,  and  liquor  amnii  are  drawn  into  the  respiratory  passages, 
preventing  any  possibility  of  resuscitating  the  infant.  Dubois  gives  the 
average  of  1  death  to  1 1  deliveries. 

Is  the  maternal  prognosis  more  grave  in  breech  than  in  vertex 
presentations  ? 

It  is  not.  Although  the  first  stage  is  likely  to  be  prolonged  and 
tedious,  the  second  is  usually  much  more  rapid  than  in  vertex  labors,  so 
that  the  entire  labor  is  not  unusually  long. 

How  may  a  pelvic  presentation  be  diagnosed  before  labor  has 
begun  ? 

Pidpation. — As  described  on  page  110,  we  find  a  broad  mass  in  the 
iliac  fossae,  nearly  immovable  and  resting  higher  up,  out  of  the  pelvis. 
Small  parts  of  the  foetus  may  be  appreciated  in  the  lower  segment  of 
the  uterus,  and  above  in  the  fundus  the  head  is  found.  If  cephalic  bal- 
lottement  is  obtained,  the  diagnosis  of  the  extremity  is  certain.  Auscul- 
tation reveals  the  maximum  intensity  of  the  foetal  heart-sounds  on  a  level 
with  or  above  the  umbilicus.  On  vaginal  examination,  as  a  rule,  nothing 
can  be  felt.  The  breech  lies  high  up  and  away  from  the  examining 
finger,  though  occasionally  an  extremity  can  be  found.  On  the  slightest 
pressure  this  will  glide  away  from  the  finger  as  though  drawn  up  by  the 
foetus.     Such  a  sensation  would  make  the  diagnosis  assured. 

How  may  a  pelvic  presentation  be  diagnosed  after  labor  has 
begun  ? 
On  palpating  and  auscultating  the  same  condition  of  affairs  is  found  as 
described  above.  If  the  membranes  be  still  intact  when  a  vaginal  exam- 
ination is  made,  little  will  be  discovered,  unless  the  os  is  dilated,  except- 
ing a  peculiar  feel  to  the  bag  of  waters.  It  is  longer  and  more  conical. 
Now,  if  we  examine  when  the  cervix  is  more  dilated  and  the  membranes 
ruptured,  the  diagnosis,  as  a  rule,  is  very  easily  made.  The  finger  first 
comes  in  contact  with  a  soft,  fleshy  mass.  No  sutures  or  fontanelles  are 
felt,  and  on  passing  backward  a  groove  is  reached,  and  beyond  a  mass 
similar  to  the  part  with  which  our  finger  first  came  in  contact  is  discerned. 
Following  the  groove,  first  in  one  direction  and  then  in  the  other,  we 
feel  on  one  side  a  small  osseous  point,  the  coccyx.  Pushing  farther  up- 
ward, the  spinous  processes  of  the  sacrum  may  be  distinguished.  In  the 
other  direction  we  find  the  anus,  and  if  the  finger  can  be  introduoed  this 
is  readily  recognized  by  the  contraction  of  the  sphincter  and  the  presence 


PELVIC   PRESENTATIONS.  105 

of  meconium,  which  covers  the  finger.  In  front  of  the  anus  the  genital 
organs  are  found.  If  the  feet  be  pressed  against  the  buttocks,  they  may 
be  felt  and  the  character  of  the  presentation  readily  determined.  The 
position  is  recognized  by  the  position  of  the  sacrum. 

From  what  must  the  breech  be  differentiated? 

The  only  presentation  with  which  a  breech  may  be  confounded  is  a 
face,  and  then  only  when  the  labor  has  been  much  prolonged  and  the 
parts  very  oedematous.  The  mouth  is  differentiated  from  the  anus  by 
the  alveolar  ridges  in  the  former  and  the  sphincteric  action  in  tlie  latter. 
Nothing  resembling  the  sacral  spines  can  be  felt  in  a  face,  and  nothing 
resembling  the  nostrils  in  a  breech. 

How  would  you  recognize  the  foot  or  knee? 

The  only  part  the  former  might  be  confounded  with  is  the  hand. 
Bearing  in  mind  these  points,  the  mistake  will  never  be  made.  The 
toes  are  shorter  than  the  fingers  and  placed  in  a  straight  line.  The 
thumb  can  be  brought  in  contact,  across  the  palm  of  the  hand,  with  any 
of  the  fingers  ;  the  great  toe  cannot.  The  thumb  and  first  finger  may  be 
considerably  separated  ;  the  toes  cannot.  Nothing  resembling  the  mal- 
leoli or  the  heel  can  be  found  on  the  hand.  Last  of  all,  the  hand  lies 
on  a  straight  line  with  the  arm  ;  the  foot  is  at  right  angles  to  the  leg. 
The  foot  felt  (right  or  left)  is  determined  by  finding  the  great  toe,  the 
internal  border,  and  the  heel,  and  by  imagining  one's  own  foot  in  the 
same  position.  The  knee  is  appreciated  as  a  smooth,  rounded  mass  with 
two  tuberosities  and  a  deep  depression  behind. 

Describe  the  management  of  pelvic  presentations. 

In  managing  a  pelvic  presentation  we  seek,  first,  to  keep  the  mem- 
branes intact  until  they  reach  the  perineum  if  possible,  that  dilation  of 
the  cervix  may  be  complete ;  second,  to  maintain  flexion  of  the  head ; 
third,  to  hasten  delivery  after  the  trunk  is  born  ;  fourth,  to  prevent  ex- 
tension of  the  arms  and  head  by  improper  interference. 

When  labor  has  begun,  always  remain  with  the  patient  and  keep  her 
very  quiet,  that  no  movement  on  her  part  may  cause  premature  rupture 
of  the  membranes.  If  rupture  has  not  taken  place  when  the  bag  of 
waters  has  reached  the  outlet  of  the  pelvis,  it  should  be  artificially 
ruptured.  The  foot  now  appears  at  the  vulva,  and/rom  this  time  on  the 
hand  of  an  assistant — preferably,  the  accoucheur  if  necessary — should 
keep  up  constant  pressure  over  the  fundus  uteri.  As  the  feet  descend, 
followed  by  the  buttocks,  support  them  with  the  hand,  but  do  not  make 
any  traction.  As  soon  as  the  genital  organs  have  emerged  from  the 
vulva,  pass  the  hand  along  the  child's  abdomen,  secure  the  cord,  and 
draw  a  loop  downward.  If  pulsations  are  present,  allow  nature  to  take 
its  course,  raising  the  body  of  the  child  from  the  bed  with  each  contrac- 


106 


UNNATURAL    LABORS. 


tion,  and  keeping  uj)  firm  pressure  over  the  fundus.  At  the  same  time 
encouraire  the  motlier  to  bear  down,  as  her  efforts  will  very  naturally 
hasten  the  delivery. 

The  arms  and  shoulders  are  then  expelled,  and  the  child  lies  with  its 
abdomen  pointing  toward  the  bed.  The  cord  will  now  be  found  pulse- 
less, and  the  life  of  the  child  at  this  point  depends  entirely  upon  the 
rapidity  of  the  delivery  of  the  head.  Raise  the  body  well  up  toward 
the  pubes  and  abdomen  of  the  mother  with  the  right  hand,  and  with 
the  first  and  second  fingers  of  the  left  reach  up  between  the  symphysis 
pubes  and  neck  of  the  child  until  the  occiput  is  felt,  and  push  down- 
ward. If  delivery  is  not  readily  accomplished,  traction  must  be  made 
on  the  trunk.  A  short  trial  at  this  method  will  soon  show  whether  or 
not  delivery  may  be  completed.  If  failure  should  meet  our  efforts,  there 
are  two  more  methods  which  may  be  tried.  One  consists  in  giving  the 
body  into  the  hands  of  an  assistant,  and  with  the  first  two  fingers  of  the 

Fig.  25. 


Delivery  of  the  Head  in  Breech  Cases. 


left  hand  introduced  over  the  face  of  the  child  downward  pressure  is 
made  on  the  two  malar  bones,  aided  by  the  pressure  on  the  occiput 
(Fig.  25) ;  or  the  forceps  may  bo  used.  Tliey  sliould  always  be  at  hand 
in  breech  deliveries,  and  are  applied  beneath  the  abdomen.     However, 


DIFFICULT   BREECH    PRESENTATIONS.  107 

bear  in  mind  that  the  dehvery  must  be  rai")id  to  secure  a  Hvin.g  child,  and 
the  first  method  described,  if  properly  done,  will  almost  invariably  be 
crowned  with  success  unless  the  head  is  extended. 

DIFFICULT   BREECH   PRESENTATIONS. 

What  are  the   most  serious   complications  met  with  in  breech 
presentations  ? 

The  failure  of  the  head  to  rotate  in  the  sacro-posterior  positions,  ex- 
tension of  the  head,  and  extension  of  the  arms. 

State  the  management  of  a  sacro-posterior  position  where  in- 
ternal rotation  does  not  occur. 

As  a  rule,  this  is  observed  either  where  a  disproportion  between  the 
maternal  pelvis  and  foetal  head  is  present,  or  where  the  head  becomes 
extended  through  improper  management  or  interference.  Tn  either 
case  our  efforts  are  in  tico  directions :  first,  to  secure  and  maintain  good 
flexion  ;  and  second,  to  assist  rotation  by  proper  manipulations. 

The  body  of  the  child  being  supported  by  the  hand  of  an  assistant, 
upward  pressure  is  made  on  the  occiput  by  the  first  two  fingers  of  the 
right  hand.  With  the  fingers  of  the  other  hand  pressure  is  made  upon 
the  anterior  temple  during  a  pain.  By  these  means  rotation,  as  a  rule, 
will  take  place.  In  case  it  does  not  and  the  head  descends  to  the  pelvic 
outlet  with  the  occiput  lying  posteriorly,  if  flexion  be  present  traction 
should  be  made  in  a  backward  direction,  that  the  neck  may  act  as  the 
point  of  rotation  and  the  face  emerge  first  under  the  pubes.  However, 
if  the  head  be  extended  the  chin  will  become  fixed  back  of  the  s^'mphysis, 
and  our  traction  must  be  made  in  a  directly  opposite  direction,  allowing 
the  occiput  and  back  of  the  head  to  first  emerge  over  the  perineum.  In 
case  extraction  cannot  be  accomplished  beibre  the  death  of  the  foetus 
has  occurred  and  the  possibility  of  resuscitation  passed,  craniotomy  may 
be  resorted  to  as  a  justifiable  and  proper  means  of  saving  the  maternal 
soft  parts  from  serious  injury. 

How  are  extended  arms  to  be  treated? 

The  arms  must  be  made  to  pass  downward  over  the  chest  of  the  child, 
but,  as  direct  traction  would  result  in  fracturing  the  delicate  bones,  we 
pass  two  fingers  over  the  shoulder  and  down  toward  the  elbow  as  far  as 
possible  ;  then  make  gentle  pressure.  The  arm  will  slip  by  the  face,  and 
by  passing  the  fingers  i'arther  along  the  forearm  is  made  to  follow  in  the 
same  direction.  When  both  are  extended  the  posterior  is  the  first  to  be 
liberated,  as  more  room  for  manipulation  is  found  in  this  part  of  the 
pelvis. 

What  is  an  impacted  breech  presentation  ?   Describe  its  manage- 
ment. 

A  breech  becomes  impacted  in  the  pelvis  when  a  marked  disproportio: 


108 


UNNATURAL   LABORS. 


exists  between  it  and  the  pelvis,  even  though  the  attitude  of  the  foetus 

be  normal.     In  such  eases 
Fig.  26.  normal    progress    of   the 

labor  may  usuallj'^  be  ob- 
tained by  drawing  down 
one  of  the  legs,  and  thus 
breaking  up  the  impac- 
tion. In  other  words,  sub- 
stitute a  half  for  a  full 
breech.  However,  when 
reference  is  made  to  an 
impacted  breech  we  usual- 
ly understand  it  to  be  one 
in  which  the  limbs,  though 
flexed  at  the  thighs,  are 
extended  at  the  knees. 
This  forms,  as  it  were,  a 
wedge,  the  small  part  of 
which  is  the  breech  and 
the  large  part  the  head 
and  feet  of  the  child  (Fig. 
26). 

Although  impaction 
does  not,  as  a  rule,  occur 
until  after  the  breech  is 
well  in  the  pelvis,  treat- 
ment should  be  resorted 
to  as  soon  as  the  os  is  well 
dilated  and  the  condition  recognized.  In  the  natural  breech  the  practi- 
tioner can  always  feel  a  foot,  heel,  or  toe,  but  in  these  cases  he  cannot ; 
and  if  not,  he  will,  by  abdominal  j)alpation,  discover  the  feet  lying  in  the 
fundus  of  the  uterus  by  the  child's  head.  If  the  back  of  the  foetus  is 
toward  the  right  side  of  the  mother,  the  right  hand  is  introduced  into 
the  uterus,  a  foot  seized  and  drawn  down.  If  the  back  lies  toward  the 
left  side  of  the  mother,  the  left  hand  of  the  accoucheur  is  used.  The 
labor  is  now  allowed  to  progress  naturally. 

For  carrying  out  the  above  procedures  chloroform  or  ether  to  the  sur- 
gical degree  should  be  given. 

Other  causes  arise  where  the  impaction  is  found  too  late  in  the  labor 
to  allow  of  the  hands  being  passed  by  the  breech  and  up  into  the  uterus. 
Two  methods  for  treating  these  cases  are  used  by  diiferent  practitioners : 
one  is  to  apply  the  forceps  to  the  breech ;  this  is  not  advisable.  The 
other  is  to  make  traction  with  an  instrument,  or  with  a  piece  of  clotli  or 
the  fingers  passed  over  the  groin.  The  best  of  these  three  is  either  the 
finger  or  a  soft  folded  cloth. 


Pelvic  fresentatiou  with  Legs  Extended. 


PRESENTATIONS   OF   THE   TRUNK. 
PRESENTATIONS   OF   THE   TRUNK. 


109 


What  are  the  positions  of  the  foetus  in  transverse  presentations  ? 
and  which  is  the  most  frequent? 

The  term  ''transverse  presentation"  is  somewhat  misleading,  inas- 
much as  the  child  never  lies  directly  transversely,  but  always  in  an 


Fig.  27. 


Fig.  28. 


L.  D.  A. 


R.  D.  A. 


oblique  diameter  of  the  uterus  midway  between  the  vertical  and  the 
transverse :  therefore,  the  shoulder,  elbow,  or  arm  are  the  parts  found 
presenting.     There  are  four  positions — namely,  ( 1 )  left  dorso-anterior,  in 


Fig  29. 


Fig.  30. 


R.  D.  P. 


which  the  head  lies  in  the  left  iliac  fossa  and  the  back  points  anteriorly 
(Fig.  27) ;  (2)  right  dorso-anterior.  in  which  the  head  lies  in  the  right 
iliac  fossa  with  the  back  of  the  child  anterior  (Fig.  28) ;   (3)  left  abdom- 


110  UNNATURAL   LABORS. 

ino-anterior  or  dorso-posterior,  which  corresponds  to  the  one  first  men- 
tioned, except  that  the  abdomen  hes  anteriorly  and  the  back  toward  the 
mother's  baclc  (Fig.  29) ;  (4)  right  abdomi no-anterior,  in  which  the  head 
hes  in  the  right  ihac  fossa  and  the  abdomen  points  anteriorly  (Fig.  30). 
The  most  frequent  are  the  two  first  mentioned,  and  of  these  the  left 
dorso-anterior  is  the  one  most  commonly  met  with. 

How  frequently  do  presentations  to  the  trunk  occur? 

According  to  some,  they  are  found  as  often  as  1  in  125,  while  others 
give  their  frequency  as  1  in  250  or  300. 

State  the  causes  of  transverse  or  shoulder  presentations. 

31ultiparity ;  a  too  pronounced  uterine  obliquity ;  pelvic  deformities, 
especially  a  jutting  forward  of  the  sacrum  ;  excess  of  liquor  amnii ;  pre- 
maturity ;  deformities  of  the  foetal  head  ;  placenta  praevia,  or  a  low  im- 
plantation of  the  placenta,  which  prevents  the  head  from  lying  in  the 
lower  uterine  segment, — are  among  the  many  causes  given.  Then,  also, 
accidents  may  occur,  which  have  a  decided  influence  in  determining  this 
form  of  presentation.  Falls  and  irregular  pressure  over  the  abdomen 
may  materially  aid  in  determining  a  shoulder  presentation  where  a  tend- 
ency toward  this  exists  in  the  way  of  uterine  obliquity  and  lax  ab- 
dominal walls. 

How  would  you  diagnose  a  trunk  presentation  before  the  mem- 
branes have  ruptured? 

Inspection  shows  an  unsymmetrical  appearance  of  the  uterine  tumor, 
with  a  bulging,  rounded  mass  in  one  iliac  fossa.  This  is  especially  ap- 
parent in  thin  women  who  have  lax  abdominal  walls.  Palpation  reveals 
the  absence  of  any  mass  occupjnng  the  inferior  uterine  segment,  but 
shows  the  presence  of  such  a  mass  in  one  iliac  fossa  and  on  the  opposite 
side  of  the  abdomen ;  and,  lying  much  lower  down  than  would  the  breech 
in  vertex  or  the  vertex  in  breech  presentations,  is  found  another  mass. 
The  smooth,  hard,  even  surface  of  the  back  or  the  irregular  abdominal 
surface  of  the  foetus  can  be  appreciated  as  lying  in  an  oblique  diameter 
of  the  uterus.  Auscultation  reveals  the  greatest  intensity  of  the  foetal 
heart-sounds  considerably  higher  up  than  is  the  case  when  the  vertex 
presents.  By  vaginal  examination  nothing  but  a  flabby  vaginal  canal 
and  empty  lower  uterine  segment  can  be  felt. 

How  would  you  diagnose  a  trunk  presentation  after  rupture  of 
the  membranes? 

Inspecti(jn,  palpation,  and  auscultation  are  productive  of  the  same  re- 
sults. In  making  a  vaginal  examination,  unless  some  part  of  the  arm  or 
hand  are  })rolapsed,  we  feel  nothing.  As  a  positive  diagnosis  nmst  be 
made  as  early  as  possible,  chloroform  or  ether  should  be  given,  and  the 
hand  gradually  introduced,  cone-shaped,  into  the  vagina.  The  two  fin- 
gers now  being  passed  through  the  cervix,  the  smooth,  rounded  promi- 


PRESENTATIONS   OF   THE   TRUNK.  Ill 

nences  of  the  shoulder  with  its  sharp  acromion  process  may  be  felt. 
Passing  around  it,  the  axilla  is  recognized,  and  then  the  ribs.  When 
the  latter  are  felt  the  diagnosis  is  positive.  The  exact  position  of  the 
child  is  ascertained  ?jy  finding  in  which  iliac  fossa  the  head  lies.  If  this 
has  not  been  determined  by  palpation,  we  will  know  as  soon  as  the  axilla 
is  felt,  since  it  always  points  toward  the  feet.  We  determine  the  posi- 
tion of  the  back  through  the  vaginal  examination  by  feeling  the  spine 
of  the  scapula  either  in  front  or  posteriorly.  In  case  the  elbow  lies  at 
the  OS,  it  is  readily  recognized  by  the  sharply  projecting  olecranon  process 
lying  between  the  two  smaller  prominences,  the  condyles.  The  method 
of  differentiating  the  hand  from  the  foot  has  already  been  given. 

Finding  a  hand  projecting  from  the  vulva,  how  would  you  de- 
termine whether  it  was  the  right  or  left  hand? 

Imagine  one's  own  hand  placed  in  the  same  position  as  that  of  the 
foetus,  and  we  know  immediately  which  it  is.  Or  take  hold  of  it  as 
though  to  shake  hands :  if  the  two  palms  and  thumbs  lie  in  apposition, 
it  must  be  the  right  hand;  if  not,  it  is  the  left.  The  position  of  the 
body  of  the  child  can  also  be  recognized  by  the  hand,  provided  we  feel 
sure  it  is  supinated,  as  its  back  must  point  to  the  back  of  the  child  and 
its  palm  to  the  abdomen. 

Upon  what  does  the  prognosis  of  this  form  of  presentation  de- 
pend? 

Upon  the  time  when  the  position  is  recognized,  upon  its  management, 
the  cause  of  the  presentation,  and  the  facility  with  which  version  can  be 
done.  For  the  mother  it  is  exceedingly  bad  when  a  deformed  pelvis  has 
been  the  determining  cause  or  when  labor  has  been  much  prolonged  be- 
fore treatment  is  undertaken.  Churchill  estimates  a  loss  of  1  out  of  9 
mothers  in  235  cases.     About  60  per  cent,  of  the  children  are  lost. 

How  may  these  cases  terminate? 

There  can  be  no  mechanism  to  them,  but  there  are  two  ways  possible 
for  them  to  terminate — namely,  by  ' '  spontaneous  version  "  or  by  "  spon- 
taneous evolution. ' ' 

What  is  spontaneous  version  ? 

This  can  only  occur  with  a  living  foetus,  and  may  take  place  during  the 
latter  weeks  of  pregnancy  or  after  labor  has  begun.  It  is  the  substituting 
of  the  vertex  or  breech,  over  the  cervix,  for  the  shoulder.  The  probable 
cause  of  this  very  fortunate  but  rare  occurrence  is  irregular  uterine  con- 
traction, and  this  termination  is  rendered  wellnigh  impossible  after  the 
membranes  have  ruptured  and  the  liquor  amnii  has  been  evacuated. 

What  is  "  spontaneous  evolution,"  and  when  does  it  occur  ? 

It  is  the  birth  of  the  child  folded  as  it  were  upon  itself  (Fig.  31).  It 
can  only  take  place  during  labor  and  with  a  dead  foetus,  unless  under 
very  favorable  conditions — namely,   an  exceedingly  roomy  pelvis  and 


112 


UNNATURAL   LABORS. 


small  child  or  a  premature  infant.     Under  these  circumstances  living 
foetuses  have  been  born  by  spontaneous  evolution.     Two  varieties  have 

Fig.  31 . 


Spontaneous  Evolution. 


been  observed :  in  one  the  head  is  born  first ;  in  the  other,  the  breech. 
The  former  can  take  place  only  with  very  premature  children.     In  the 


COMPLEX    PRESENTATIONS.  113 

latter  the  child  is  crowded  tightly  down  within  the  pelvis,  the  presenting 
shoulder  lying  behind  and  the  head  above  the  pubes.  With  the  head 
and  shoulders  fixed  here  the  body  rotates,  so  that  the  breech  is  crowded 
out  of  the  pelvis  over  the  perineum.  The  head  is  the  last  part  of  the 
child  to  be  expelled. 

Describe  the  management  of  shoulder  presentations  if  discerned 
before  labor  has  begun. 

These  cases  should  be  treated  by  doing  a  cephalic  version.  After  the 
head  has  been  pushed  down  over  the  cervix  and  the  breech  up  in  the 
fundus,  a  pad  is  to  be  applied  over  the  abdomen  by  the  side  of  the  head, 
and,  to  hold  this  in  place,  an  abdominal  binder.  By  these  means  we  pre- 
vent the  slipping  back  of  the  head  to  its  former  position  in  one  ihac 
fossa. 

Describe  the  management  of  shoulder  presentations  after  labor 
has  begun. 

In  these  cases  one  of  three  methods  of  version  must  be  resorted  to — 
external  cephalic  version  if  possible;  faihng  in  this,  the  bimanual  method 
should  be  tried,  but  cases  are  found  where  neither  will  succeed,  and  in 
these  the  internal  version  must  be  performed.  Faihng  in  all  these,  two 
resources  remain  :  the  destruction  of  the  foetus  (embryotomy)  and  a  Csesa- 
rean  section.  The  obstetric  operations  above  spoken  of,  versions,  em- 
bryotomy, and  Csesarean  section,  will  be  described  farther  on. 

COMPLEX  PRESENTATIONS. 

How  would  you  treat  a  case  where  the  hand  was  found  pre- 
senting with  the  head? 

It  occasionally  happens  that  the  hand  is  drawn  back  by  the  child  itself. 
If  this  does  not  occur,  we  attempt  to  gently  force  it  back  during  the  in- 
tervals between  the  pains.  The  head  will  now  usually  descend  sufficiently 
to  prevent  its  again  slipping  down.  However,  if  it  tends  to  return  to 
the  abnormal  position,  the  forceps  must  be  applied  and  the  head  en- 

faged,  care  being  taken  not  to  catch  the  arm  with  one  of  the  blades, 
f  the  foot  is  found  presenting  with  the  head,  the  same  plan  of  manage- 
ment may  be  pursued.     This,  however,  is  of  very  infrequent  occurrence. 

State  the  management  of  a  case  where  the  arm  lies  across  the 
back  of  the  neck. 

The  diagnosis  of  these  cases  is  very  difficult,  and,  unless  by  exclusion, 
can  be  made  only  after  an  anaesthetic  has  been  administered  and  the 
hand  introduced  into  the  vagina.  The  obstruction  to  the  descent  of  the 
head  occurs  so  high  up  that  by  ordinary  vaginal  examination  it  cannot 
be  felt.  The  condition  being  recognized,  the  patient  may  be  placed 
under  the  influence  of  chloroform  and  an  attempt  made  to  replace  the 
hand  and  forearm.  This,  however,  is  not  likely  to  prove  successful,  and 
podalic  version  must  be  resorted  to. 
8— Obs. 


114 


UNNATURAL   LABORS. 


What  treatment  must  be  pursued  when  a  hand  and  foot  are 
found  presenting? 
Podalic  version.     As  traction  is  made  on  the  foot,  upward  pressure 
upon  the  shoulder  causes  the  hand  to  recede,  and  a  half  breech  is  sub- 
stituted for  the  hand  and  foot. 


PROLAPSE   OF  THE  FUNIS. 

What  is  prolapse  of  the  umbilical  cord?  and  with  what  pres- 
entation does  it  most  frequently  occur? 

It  is  the  falling  down  of  a  loop  of  the  cord  bej^ond  the  presenting  part 
of  the  fcetus  (Fig.  32).     This  loop  becomes  compressed  between  the 

presenting  part  and  the  walls 
Fio.  32.  of  the  pelvis,   the  circulation 

is  interfered  with  or  checked, 
and  asphyxia  and  death  of  the 
foetus  result.  It  most  fre- 
quently occurs  with  breech  or 
transverse  presentations. 

State  the  causes  and  fre- 
quency of  this  compli- 
cation. 

Any  condition  which  pre- 
vents the  presenting  part  of 
the  foetus  from  accurately  fit- 
ting the  pelvic  brim  is  condu- 
cive to  prolapse  of  the  funis. 
Thus  we  find  it  most  com- 
monly in  contracted  pelves  and 
with  abnormal  presentations. 
Other  important  causes  are  an 
excessive  amount  of  liquor 
amnii  and  early  rupture  of  the 
membranes,  especially  if  the 
patient  be  in  an  upright  posi- 
tion ;  also  an  unusually  long 
cord  and  low  attachments  of 
the  placenta.  The  frequency 
is  variously  estimated  by  dif- 
in  300  labors. 


Prolapse  of  the  Funis. 

ferent  authors  as  1  case  in  100  to  1 


Under  what  circumstances  is  the  prognosis  to  the  child  most 
favorable  ? 

In  cases  in  which  the  prolapse  occurs  in  a  multipara  with  a  small  child 
and  a  breech  or  transverse  presentation.  At  best,  less  than  50  per  cent, 
of  the  children  are  saved,  and  this  mortality  is  much  increased  in  vertex 


PROLAPSE    OF   THE    FUNIS.  115 

cases  occurring  In  primiparae,  especially  if  the  prolapse  occurs  with  the 
head  high  up  in  the  pelvis  and  the  child  large  and  at  term. 

How  would  you  diagnose  and  treat  a  case  of  prolapse  of  the 
funis  ? 

After  the  rupture  of  the  membrane  the  diagnosis  is  attended  with  no 
difficulties.  However,  if  it  occurs  before  the  liquor  amnii  has  drained 
awa3^,  it  is  oftentimes  difficult  to  determine  the  condition  unless  the  pul- 
sations can  be  felt  through  the  membranes.  The  reason  of  this  is  obvious. 
Being  light  and  soft,  the  moment  the  part  is  touched  with  the  finger  it 
immediately  recedes  and  lies  bej^ond  our  reach.  If  the  condition  is  found 
before  the  membranes  are  ruptured,  the  woman  should  be  kept  quietly 
on  her  back  with  the  hips  well  elevated,  for  as  long  as  the  membranes 
remain  intact  little  or  no  pressure  can  be  exerted  upon  the  cord,  at  least 
not  until  the  os  is  completely  dilated.  As  soon  as  dilatation  is  complete 
two  or  three  fingers  should  be  introduced  into  the  vagina,  and  a  very 
small  puncture  of  the  membrane  made,  that  the  escape  of  the  liquor 
amnii  may  be  slow  and  the  great  danger  of  a  large  loop  of  the  cord 
being  washed  out  avoided.  Upward  pressure  upon  the  prolapsed  loop 
should  be  tried  as  soon  as  the  liquor  amnii  has  drained  away,  and  an 
attempt  be  made  to  crowd  the  head  into  the  pelvis  by  pressure  over  the 
abdomen.  If  this  succeeds  and  the  cord  remains  in  its  normal  position, 
and  if  we  find  the  child's  condition  good,  as  will  be  shown  by  the  foetal 
heart-sounds,  the  labor  maybe  allowed  to  terminate  by  the  natural  forces. 
Such  a  favorable  termination,  however,  though  the  most  desirable,  can- 
not always  be  looked  for,  and  recourse  to  more  active  methods  of  treat- 
ment must  be  had.  There  are  four  procedures  which  may  be  attempted, 
no  one  of  which  is  adapted  to  every  case:  (1)  postural  treatment; 
(2)  artificial  reposition  by  instruments;  (3)  the  use  of  the  forceps; 
(4)  version  in  vertex  cases. 

The  method  of  procedure  in  the  first  form  of  treatment  is  to  place  the 
patient  in  the  knee-elbow  position.  This  elevates  the  hips,  and  naturally 
the  cervix;  at  the  same  time  it  lowers  the  fundus  of  the  uterus  ;  thus  its 
anterior  wall  forms  a  smooth  inclined  plane  down  which  the  cord  may 
pass.  Before  the  rupture  of  the  membranes  this  method  will  almost 
invariably  be  crowned  with  success,  and  it  is  only  necessary  to  rupture 
them  and  allow  the  woman  to  carefully  turn  over  upon  the  back.  If  the 
cord  again  slips  down,  the  same  manoeuvre  should  be  repeated,  pressure 
being  made  upon  the  abdomen  while  in  the  knee-elbow  position,  that  the 
head  may  be  engaged  and  prevent  the  loop  from  again  slipping  down. 
After  the  escape  of  the  liquor  amnii  this  procedure  is  not  so  likely  to 
prove  successful.  It  may  be  tried,  however,  and  often,  if  the  head  can 
be  pushed  up,  the  cord  will  slip  back.  The  simplest  instrument  for 
accomplishing  reposition,  and  at  the  same  time  one  that  is  most  likely  to 
be  at  hand,  is  a  gum-elastic  catheter.  This  is  prepared  by  passing  the 
two  ends  of  a  narrow  piece  of  tape  through  the  end  and  drawing  them 
down  until  they  emerge  at  the  eye  of  the  catheter.     Allow  the  loop  (an 


116  ANOMALIES    OF    THE    FORCES    IN    LABOR. 

incli  and  a  half  or  two  inches)  to  project  through  the  end.  This  is  passed 
around  the  cord  and  shpped  over  the  point  of  the  catheter.  Gently 
drawing  down  on  the  ends  of  the  tape  which  emerge  from  the  open- 
ing, the  cord  is  firml.y  held  in  position  and  carried  up  beyond  the 
he^d  by  pushing  the  whole  arrangement  upward.  A^'^^V  ^^^  prolapsed 
portion  is  well  up  above  the  head  the  catheter  alone  is  withdrawn.  The 
use  of  the  forceps  is  demanded  when,  with  a  roomy  pelvis,  the  cord  per- 
sists in  relapsing  after  being  replaced.  They  should  be  applied,  and  as 
traction  is  made  the  cord  pushed  upward.  If  after  engaging  the  head 
the  foetal  heart  shows  that  the  circulation  is  not  interfered  with,  they 
may  be  removed  and  the  labor  allowed  to  terminate  naturally.  If  not, 
the  head  must  be  ra]3idly  drawn  through  the  pelvis.  It  is  obvious  that 
this  method  of  rapid  delivery  should  not  be  attempted  unless  the  pelvis 
be  amply  large  or  the  head  very  small.  Version  is  applicable  as  a  last 
resort  or  in  cases  in  which  the  forceps  are  inadmissible  on  account  of  a 
small  or  primiparous  pelvis. 

ANOMALIES  OF  THE  FORCES  IN  LABOR. 

PROTRACTED  LABOR. 

State  the  causes  of  prolonged  labor,  and  when  does  the  delay 
occur. 
Many  pelvic  deformities  and  inelasticity  of  the  parturient  canal,  as 
well  as  tumors  and  foetal  deformities,  cause  prolonged  or  protracted 
labors ;  but  the  term  is  used  only  in  those  cases  in  which  the  delay  is  due 
to  a  defectively  acting  uterus.  Thus,  its  walls  may  be  very  thin,  allowing 
only  weak  contractions  or  perhaps  an  entire  absence  of  them.  This  is 
seen  in  women  marrying  too  young,  as  the  organ  is  not  fully  developed. 
A  conlition  of  uterine  inertia  is  also  frequently  seen  in  multiparae  who 
have  borne  a  large  number  of  children.  The  organ  is,  as  it  were,  worn 
out.  Enfeebled  constitution  and  long  residence  in  tropical  climates,  by 
enfeebling  the  nervous  powers,  cause  inertia.  Mental  conditions,  excess 
oF  liquor  amiiii,  and  displacements  of  the  uterus  are  also  causes.  The 
delay,  as  a  rule,  occurs  in  the  second  stage  of  labor.  However,  this  is 
not  always  the  case.  A  prolonged  first  stage,  if  the  membranes  remain 
intact,  is  of  little  consequence  to  either  the  mother  or  the  child,  though 
this  is  not  so  if  the  liquor  amnii  has  drained  away,  as  both  the  child  and 
the  uterus  are  exposed  to  constant  and  oftentimes  injurious  pressure. 

State  the  dangers  and  symptoms  of  a  prolonged  labor. 

To  the  child  the  dangers  arise  from  the  ctjnstant  and  prolonged  com- 
pression of  the  head,  as  is  shown  by  the  gradual  diminution  in  the  fre- 
quency, strength,  and  regularity  of  the  foetal  heart.  To  the  mother 
exhaustion  comes,  as  it  must  with  prolonged  suffering  of  any  kind. 
Injury  to  the  soft  structures  occurs,  resulting  at  times  in  sloughing  and 
septic  infections.  The  thin  uterus,  perhaps  through  interference,  per- 
haps simply  through  a  uterine  contraction,  ruptures,  and  death  results. 


PROTRACTED    LABOR.  117 

Post-partum  hemorrhage  is  of  frequent  occurrence  in  these  cases,  and  as 
a  rule  is  difficult  to  control. 

Sym2)to'ms. — Labor  perhaps  progresses  normally  until  the  head  has 
emerged  from  the  os,  and  then  the  pains  cease  or  become  very  infre- 
quent, irregular,  of  short  duration,  and  inexpulsive.  The  pulse,  which 
has  been  80  or  90  up  to  this  time,  rises  to  110  or  120;  the  patient 
becomes  irritable  and  very  restless.  Nausea,  vomiting,  and  a  coated 
tongue,  accompanied  by  a  rise  of  temperature  to  100°  or  101°  F. ,  now 
follow.  The  vagina  is  hot,  dry,  and  extremely  sensitive,  and  the  secre- 
tions, which  have  been  abundant,  are  entirely  absent.  Thirst  is  intense 
and  a  complete  loss  of  appetite  is  present.  If  these  -symptoms  are 
allowed  to  continue  unrelieved,  the  vomiting  becomes  excessive ; 
delirium  occurs,  the  pulse  becomes  more  rapid,  and  at  last  impercep- 
tible; the  temperature  rises  very  high  ;  the  vagina  becomes  hotter  and 
drier ;  and  the  patient  dies  with  all  the  symptoms  of  complete  ex- 
haustion. 

Describe  the  management  of  prolonged  labors  when  delay  occurs 
during  the  first  stage. 

As  has  been  stated  above,  it  is  rare  to  meet  with  cases  in  -^vhich  a 
delayed  first  stage  requires  interference  ;  however,  cases  will  arise  where 
it  becomes  necessary  to  resort  to  treatment  of  some  kind.  If  labor  has 
been  in  progress  some  time,  the  os  is  tense  and  undilated,  and  the  patient 
irritable,  nervous,  and  wakeful,  we  should  first  see  that  the  rectum  is 
emptied  by  a  warm-water  or  soapsuds  enema.  A  prolonged  vaginal 
douche  of  a  solution  of  bichloride  of  mercury,  1  :  10,000,  at  a  tempera- 
ture of  112°  to  116°  F.,  will  often  alter  materially  the  character  and 
strength  of  the  pains.  If  more  rapid  progress  does  not  now  occur, 
chloral  hydrate,  in  gr.  x-xv  doses  every  fifteen  or  twenty  minutes  until 
thirty  or  forty-five  grains  are  taken,  will  promote  dilatation  of  the  os 
and  allow  of  some  sleep  between  the  uterine  contractions.  Or  a  hypo- 
dermic of  Magendie's  solution  of  morphine,  ■fr^vj  to  viij,  may  be  given. 
After  a  few  hours'  sleep  the  patient  will  awaken  refreshed,  and  labor 
will  now  be  rapidly  completed.  As  soon  as  the  os  is  dilated  sufficiently 
to  allow  of  the  introduction  of  the  fingers,  they  should  be  passed  up  and 
swept  around  the  lower  segment  of  the  uterus,  carefully  dissecting  the 
membrane  from  its  walls,  as  undue  adhesion  is  frequently  a  cause  of 
tardy  or  slow  dilatation.  Often  much  can  be  accomplished  by  the  intro- 
duction of  one  or  two  fingers  within  the  cervix,  and  in  the  interval 
between  the  pains,  by  gradually  stretching  it.  If  all  methods  meet  with 
failure,  recourse  may  be  had  to  the  use  of  Barnes'  hydrostatic  dilators. 
The  smallest  size  is  first  introduced  ;  after  this  is  expressed,  the  second 
size,  and  so  on  until  the  largest  has  been  used,  waiting  each  time  for  the 
natural  expression  of  one  before  the  introduction  of  a  second. 

In  cases  where  the  inertia  uteri  is  due  to  an  over-distended  organ  from 
an  excessive  amount  of  liquor  amnii,  the  fluid  must  be  evacuated,  and  in 


118  ANOMALIES   OF   THE   FORCES    TX    LABOR. 

sucli  cases  the  rupture  of  the  membranes  before  the  dilatation  of  the  os 

is  complete  is  i)erfectly  justifiable. 

Describe  the  management  of  prolonged  labors  when  delay  occurs 
during  the  second  stage. 

Dilatation  of  the  os  is  complete,  the  head  enters  the  pelvis,  and  here 
descent  ceases.  Our  first  step  is  to  determine  the  cause  of  delay — 
whether  it  be  a  weakness  of  the  uterine  muscles  or  a  disproportionate 
head.  If  the  former  be  the  cause,  forceps  may  be  used  with  great  suc- 
cess and  perfect  safety.  Often  it  will  be  only  necessary  to  make  traction 
a  few  times  when  the  pains  will  return  and  labor  be  terminated  nor- 
mally. The  second  class  of  cases  will  be  treated  of  under  the  head  of 
Obstructed  Labor. 

There  are  several  adjuncts  to,  or  methods  of,  treating  cases  of  pro- 
longed labor. 

The  first  is  the  use  of  oxytocic  remedies,  or  those  drugs  which,  given 
internally,  increase  the  force  of  the  uterine  contractions.  The  drug 
which  has  attained  the  most  widespread  reputation  as  an  oxytocic  dur- 
ing labor  is  quinine.  Playfair  says  :  "  It  has  no  power  in  itself  to  excite 
uterine  contractions,  but  simply  acts  as  a  general  stimulant  and  promoter 
of  vital  energy  and  functional  activity."  It  may  be  given  in  doses  of  gr. 
XV  or  XX  every  twenty  minutes  until  gr.  xl  or  xlv  are  taken,  and  often 
will  materially  promote  the  progress  of  the  labor.  Ergot  has  also  been 
used  to  some  extent  in  these  cases,  but  is  absolutely  contraindicated. 
The  contractions  caused  by  it  are  not  the  regular  uterine  contractions  of 
a  pregnant  uterus  at  term,  but  rather  a  constant  tonic  rigidity,  which 
simply  delaj^s  labor,  and  often  causes  the  death  of  the  foetus  from  the  ex- 
cessive compression  to  which  it  is  exposed.  Strychnine  has  been  used 
some  of  late,  and  with  success.  Electricity,  especially  the  faradic  current, 
has  been  used  as  a  promoter  of  uterine  contractions  by  some,  but  its 
utility  is  very  questionable.  If  applied,  the  current  should  be  given  over 
each  side  of  the  uterus  near  the  fundus.  One  other  adjunct,  occasion- 
ally resorted  to,  remains  to  be  spoken  of  This  is  the  so-called  manual 
expression.  Its  method  of  application  is  this :  The  palms  of  both  hands 
are  applied  over  the  fundus  of  the  uterus,  and  as  soon  as  a  pain  begins 
firm  pressure  is  made  in  a  downward  and  backward  direction.  This  is 
extremely  ])ainful  to  the  mother,  and  is  rarely  attended  with  any  success. 
Therefore  it  should  not  be  resorted  to  excepting  under  rare  circum- 
stances— namely,  a  premature  child  and  failure  of  the  uterus  to  contract 
when  the  head  is  at  the  pelvic  outlet. 

PRECIPITATE   LABORS. 

What  is  a  precipitate  labor  ? 

The  so-called  })recipitate  labor  is  one  which  takes  place  too  rapidl5\  It  is 
not  of  very  frequent  occurrence,  and  happens  in  this  way  :  Just  about  when 
labor  should  begin  the  woman  has  one  pain,  and  during  the  contraction 


ANOMALIES    OF    TPIE   SOFT    PARTS    IN    LABOR.  119 

the  child  and  placenta  are  horn.  This  is  the  true  precipitate  labor, 
though  we  often  designate  those  cases  as  such  in  which  one  expulsive 
pain,  just  as  the  cervix  is  almost  completely  dilated,  causes  the  birth  of 
the  child  ;  in  other  words,  cases  in  which  there  is  no  appreciable  second 
stage. 

State  the  causes  of,  and  dangers  arising  from,  precipitate  labors. 

Some  women  are  especially  afflicted  with  this  form  of  labor,  and  the 
cause  is  usually  a  large  pelvis,  lax  parturient  canal,  non -resisting  cervix, 
and  an  excessively  strongly  contracting  uterus.  The  dangers  to  the  child 
are  obviously  greater  than  to  the  mother.  The  fact  that  it  may  be  born 
at  any  time  and  place  exposes  it  to  great  risks,  as  well  as  the  danger 
arising  from  its  falling  to  the  ground  if  the  mother  be  standing,  as  is 
often  the  case.  The  dangers  to  the  mother  are  hemorrhage  from  rapid 
delivery  or  the  tearing  away  of  the  placenta  from  its  uterine  attachment ; 
inversion  of  the  uterus  from  the  dragging  on  the  cord  and  placenta  ;  and 
perineal  lacerations. 

Is  there  any  method  of  treating  these  cases  ? 

If  a  woman  is  met  with  in  whom  this  form  of  labor  has  once  occurred, 
she  should  be  kept  quietly  in  the  house  during  the  two  weeks  preceding 
the  expected  time  of  labor.  In  those  cases  in  which  the  rapidity  occurs 
during  the  second  stage,  chloroform  may  be  administered  and  the  patient 
cautioned  to  refrain  from  all  bearing-down  efforts. 

ANOMALIES  OF  THE  SOFT  PARTS  IN  LABOR 
OBSTRUCTED   LABOR. 

What  conditions  of  the  maternal  soft  parts  may  cause  delayed 
or  prolonged  and  tedious  labors? 

I.  Of  the.  Uterus  and  Appemlar/es. — (1)  Irregular  ante-partum  hour- 
glass contractions  ;   (2)  fibroid  tumors;   (3)  ovarian  tumors. 

II.  Of  the  Os  Uteri — (1)  Rigidity  or  spasm  of  the  os ;  (2)  organic 
rigidity;  (3)  occlusion ;  (4)  cancer;  (5)  catching  of  the  anterior  hp  be- 
tween the  presenting  parts  and  pubes. 

III.  In  the  Vagina. — (1)  Atresia;  (2)  cicatrices;  (3)  cystocele;  (4) 
rectocele ;  (5)  rigid  perineum ;  (6)  accumulation  of  fascal  matter  in  the 
rectum. 

IV.  At  the  Outlet. — (])  GEdema  of  the  vulva;  (2)  thrombosis  of  the 
vulva. 

What  is  the  so-called  hour-glass  contraction  of  the  uterus  ? 

This  extremely  rare  condition  has  been  described  as  a  constriction  of 
the  muscular  fibres  of  the  internal  os  uteri,  which  is  so  firm  and  persist- 
ent as  to  cause  an  almost  insurmountable  obstacle  to  the  birth  of  the 
child.  The  administration  of  chloral  in  full  doses  is  recommended,  or 
complete  anaesthesia  under  chloroform  or  ether  may  cause  a  muscular 


120  ANOMALIES   OF   THE   SOFT   PARTS   IN   LABOR. 

relaxation  which  will  permit  of  the  introduction  of  the  forceps  and 
delivery  in  this  wa}',  or  the  doing  of  a  j^odalic  version.  Failing  in  these, 
Caesarean  section  must  be  done. 

In  what  situation  are  uterine  fibroids  likely  to  cause  the  great- 
est obstacles  to  delivery?  and  what  is  the  great  danger  of 
fibroids  complicating  pregnancy? 

In  the  lower  zone  of  the  uterus  or  upon  the  cervix,  as  they  then  fill 
up  the  pelvic  cavity  or  infringe  upon  it.  and  prevent  the  descent  of  the 
foetus.  The  greatest  danger  arising  from  the  presence  of  fibroid  tumoi^s 
is  the  frequency  with  which  hemorrhage  occurs  after  delivery  in  these 
cases.  In  cases  in  which  the  tumor  is  attached  low  down,  by  placing  the 
patient  in  the  knee-chest  position  it  may  occasionally  be  pushed  up  out 
of  the  pelvis,  and  thus  allow  of  the  descent  of  the  head.  At  other 
times,  when  attached  to  the  cervix,  it  may  be  possible  to  remove  it  by 
the  ecraseur  before  labor  begins  if  discovered  in  time.  In  a  majority  of 
cases  delivery  by  the  Caesarean  section  is  the  only  possible  method,  and 
the  mortality  in  cases  operated  upon  for  this  complication  has  been  very 
high. 

What  can  you  say  in  regard  to  the  management  of  cases  in 
which  ovarian  tumors  complicate  pregnancy? 

If  the  tumor  encroaches  upon  the  pelvic  cavity  to  a  degree  which  in- 
terferes, to  the  slightest  extent,  with  delivery,  it  should  be  punctured 
and  the  fluid  withdrawn.  If  this  be  not  possible,  either  craniotomy  or 
the  Caesarean  section  must  be  done. 

State  the  causes  and  treatment  of  spasm  of  the  os  uteri. 

The  rigidity  is  usually  only  in  the  os  externum.  It  is  frequently  met 
with  in  women  of  a  highly  nervous  temperament  and  in  those  cases 
where  the  liquor  amnii  is  evacuated  at  the  beginning  of  labor.  A  dis- 
tended bladder  or  rectum  also  frequently  causes  this  condition,  and  as 
soon  as  the  catheter  is  passed  or  the  rectum  emptied  dilatation  proceeds 
normally.  Again,  we  meet  with  cases  where  a  thick  os  is  the  cause  of 
the  rigidity. 

From  what  has  already  been  said  under  the  treatment  of  prolonged 
labors,  the  management  of  these  cases  is  obvious.  Hot  vaginal  douches 
and  forcible  dilatation  with  the  fingers  may  both  be  used,  but  the  remedy 
par  excellence  is  chloral  hydrate.  Three  most  desirable  eff'ects  are  pro- 
duced by  the  proper  administration  of  this  drug :  First,  nervous  patients 
become  quiet  and  sleep  between  the  pains;  secondly,  the  frecpienc}' of 
the  contractions  is  decreased,  and  they  become  regular  and  stronger; 
thirdly,  the  os  becomes  soft  and  more  dilatable.  The  best  method  of 
administration  is  by  the  rectum. 

In  what  class  of  cases  is  organic  rigidity  of  the  os  met  with  ? 

In  multiparae  who  have  had  extensive  lacerations  of  the  cervix  with 
resulting  cicatricial  masses,  and  in  those  cases  where  a  severe  endorae- 


OBSTRUCTED    LABOR.  121 

tritis  or  cervicitis  has  been  the  cause  of  the  rigidity.  As  a  rule,  little  or 
110  treatment  is  required,  although  more  rapid  progress  is  made  if  fre- 
quent douching  is  resorted  to. 

What  is  the  cause  of  occlusion  of  the  os  ?  and  how  is  it  treated  ? 
It  is  usually  the  result  of  an  active  cervicitis  occurring  after  impreg- 
nation has  taken  place.  The  exudation  of  the  plastic  material  causes  an 
agglutination  of  the  margins  of  the  os  externum.  Occasionally,  as  in 
the  previously  described  cases,  douches  will  relieve  the  condition.  If 
not,  the  patient  should  be  placed  in  Sims' s  position,  a  speculum  intro- 
duced, and  the  cervix  examined.  The  position  of  the  os  is  apparent 
from  a  small  depression  found  upon  the  cervix.  With  a  bistoury  two  or 
three  small,  conical  incisions  are  made  at  the  depression.  The  finger 
should  then  be  pushed  through  the  cervix,  that  we  may  know  the  con- 
dition is  relieved,  and  the  labor  allowed  to  progress  normally  if,  as  is 
usually  the  case,  the  dilatation  progresses  as  it  should. 

Should  pregnancy  be  allowed  to  continue  if  carcinoma  of  the 
cervix  is  present? 

As  soon  as  such  a  condition  is  recognized  abortion  or  premature  labor 
should  be  induced.  All  are  agreed  upon  this.  If  labor  begins  before 
the  condition  is  discovered,  we  should  wait  a  short  time  to  see  if  dilata- 
tion progresses  to  any  extent;  if  not,  the  cervix  is  to  be  incised  as  already 
described.  Now,  if  delivery  does  not  occur,  we  may  resort  to  one  of  two 
procedures :  craniotomy  if  the  os  be  sufficiently  dilated,  or  Ci^sarean 
section ;  and,  as  a  rule,  in  any  case  the  choice  lies  with  the  latter. 

If  the  cervix  is  found  tightly  wedged  between  the  pubes  and 
the  head  of  the  child,  how  would  you  remove  it  ?  and  what 
are  the  dangers  if  it  is  allowed  to  remain  ? 
During  an  interval  between  the  pains  the  anterior  lip  is  taken  between 
the  fingers  and  thumb  and  squeezed.     This  will  remove  considerable 
serum  from  the  oedcmatous  portion,  and  during  the  following  pain  it  can 
be  carefully  pushed  back  over  the  head.     If  this  proeedure  does  not  suc- 
ceed, the  forceps  must  be  applied  and  delivery  hastened,  for  prolonged 
compression  of  this  part  results  in  sloughing  and  very  probably  sepsis. 

Describe  the  treatment  of  those  cases  in  which  the  obstruction 
occurs  along  the  vaginal  canal. 

(1)  Atresiia. — This  is  a  partial  closure  of  the  vagina.  It  may  be  eon- 
genital,  and  is  present  in  the  form  of  a  band  occluding  a  portion  of  the 
canal.  As  soon  as  the  head  presses  against  the  constriction  a  nick  is 
made  with  the  knife  or  scissors,  the  fingers  introduced,  and  the  band 
torn.  Imperforate  hymen  or  thin  vaginal  septa  when  met  with  should 
be  treated  in  the  same  way. 

(2)  Cicatnces. — Old  and  firm  cicatrices  may  be  found  in  the  vagina  as 
a  result  of  injuries  in  former  labors,  from  syphilis,  or  from  severe  fevers. 
Occasionally  they  may  be  dilated  by  the  continuous  use  of  Barnes'  hy- 


122  ANOMALIES    OF    THE    SOFT    PARTS   IN    LABOR. 

drostatic  dilators  before  labor  has  begun.  If  not  discovered  until  labor, 
as  they  are  made  tense  by  the  descent  of  the  head  a  slight  nick  should 
be  made  with  the  knife,  and  dilatation  may  be  accomplished  during  the 
birth  of  the  child.  Cases  of  this  kind  have  arisen  where  craniotomy 
has  been  necessary. 

(3)  Cystocde,  or  prolapse  of  the  bladder  and  anterior  vaginal  wall,  has 
given  rise  to  an  obstruction,  but  only  in  cases  where  the  bladder  has  been 
allowed  to  become  distended.  As  a  rule,  a  soft,  elastic  male  catheter 
can  be  passed  with  little  difficulty,  and  after  the  withdrawal  of  the  urine 
the  relaxed  anterior  vaginal  wall  can  easily  be  pushed  beyond  the  de- 
scending head.  If  the  catheter  cannot  be  passed,  a  fine  aspirator  may 
be  used  to  puncture  the  bladder  and  remove  the  urine. 

A  few  rare  cases  are  on  record  where  with  a  cystocele  a  large  calculus 
is  present.  If  the  condition  is  recognized  during  pregnane}^ — and  this 
is  likely  to  be  the  case — it  should  be  removed  ;  if  not  discovered  until 
labor  is  well  advanced,  an  attempt  must  be  made  to  push  it  out  of  the 
pelvis  by  placing  the  woman  in  the  knee-elbow  position.  Failing  in  this, 
a  vesico-vaginal  fistula  must  be  made  and  the  obstruction  removed 
through  the  opening. 

(4)  Rectocele  will  never  cause  an  obstruction  of  any  moment  unless 
the  bowel  be  filled  with  hard  f^cal  matter.  Naturally,  in  such  cases  the 
condition  is  relieved  as  soon  as  the  rectum  has  been  emptied. 

(5)  Rigidity  of  the  Perineum  may  be  the  result  of  cicatricial  harden- 
ing after  injury  during  previous  labors,  but  is  most  often  found  in  pri- 
mipar?e  in  whom  the  pubic  arch  is  narrow.  This  jDrevents  the  occiput 
from  fitting  snugly  under  the  symphysis,  and  as  a  result  rupture  of  the 
perineum  is  almost  inevitable.  When  the  perineal  body  begins  to  bulge, 
chloroform  must  be  freely  administered,  and  an  attempt  made  to  stret<?h 
it  with  the  fingers.  Episiotomy  may  be  of  benefit  in  these  cases  if  prop- 
erly done. 

State  the  management  of  those  cases  where  delay  occurs  from 
CBdema  of  the  vulva. 

This  condition,  when  found,  is  usually  associated  with  albuminuria. 
As  the  head  descends  the  oedema  becomes  more  marked.  By  making 
numerous  fine  punctures  with  a  needle  very  rapid  diminution  in  size 
takes  place. 

Where  does  the  effusion  take  place? 

Generally  in  one  or  both  labia.  It  may,  however,  extend  to  all  the  sur- 
rounding cellular  tissue,  even  extending  up  to  the  abdomen.  The  strong 
"bearing-down"'  effoi'ts  of  the  mother  as  the  head  is  about  to  pass  the 
vulva,  especially  if  a  varicose  condition  of  the  veins  in  this  region  exists, 
is  the  deciding  cause  of  injury. 

Describe  the  symptoms  and  treatment. 

Pain,  tenderness,  and  swelling,  associated  with  mild  or  severe  consti- 
tutional symptoms  depending  upon  the  character  and  extent  of  the 


ANOMALIES   OF   THE    PELVIS    IN    LABOR.  123 

eifusion,  constitute  the  signs  b}^  which  a  diaffiiosk  is  readil}^  made. 
The  pain  is  of  a  tearing  character,  very  severe,  and  shooting  down  tlie 
thighs  and  up  the  back.  The  swelhng  appears  as  a  hard  mass  at  the 
site  of  the  eft'usion,  and  is  extremely  sensitive  to  the  shghtest  jiressure. 

T^he  constitutional  symptonia  are  those  resulting  from  the  loss  of  blood  if 
rupture  occurs  externally  and  the  hemorrhage  be  not  readily  checked. 
These  cases  may  terminate  by  absorption  if  the  amount  of  extravasated 
blood  be  small ;  or  if  rupture  does  not  occur  at  the  time  of  the  accident, 
suppuration  and  slough  in  o;  of  the  tumor  may  result. 

The  treatment  consists  in  the  immediate  application  of  ice  over  the  seat 
of  effusion.  If  the  tumor  is  not  large  enough  to  prevent  delivery,  this 
should  be  hastened  by  the  use  of  the  forceps.  If  delivery  is  impossible, 
owing  to  the  extent  of  the  effusion,  an  incision  should  be  made,  the  coag- 
ula  removed,  and  the  wound  packed  to  prevent  hemorrhage.  It  may 
even  be  necessary  to  use  styptics  or  the  actual  cautery  to  accomplish 
this.  If  no  difficulty  occurs  during  the  delivery  or  if  the  tumor  appears 
afterward,  the  constant  application  of  cold  or  an  evaporating  lotion  will 
often  rapidly  promote  absorption."'"  If  suppuration  occurs,  of  course  the 
tumor  must  be  opened  and  treated  as  an  ordinary  abscess. 

ANOMALIES  OF  THE  PELVIS  IN  LABOR. 

MALFORMATIONS. 

What  is  a  malformation  of  the  pelvis  ? 

Whenever  the  pelvis  varies  from  the  normal  type  to  such  an  extent  as 
to  render  labor  difficult  or  dangerous  for  the  mother,  the  child,  or  both, 
it  is  said  to  be  malformed.  Deviations  from  the  normal  may  exist  in  the 
form,  structure,  and  dimensions  of  the  pelvis  or  in  the  direction  of  its 
planes  and  axes.  There  are,  accordingly,  three  principal  varieties: 
pelves  that  are  too  large,  those  that  are  too  small,  and  those  having  an 
abnormal  inclination  (Charpentier). 

State  the  causes  of  pelvic  deformity. 

(1)  Arrest  of  development  or  growth,  which  causes  a  funnel-shaped, 
masculine,  or  justo-minor  pelvis;  (2)  softness  of  the  bones  from  disease 
(rickets  and  osteomalacia);  (3)  muscular  contractions;  (4)  undue  pres- 
sure at  any  point. 

Describe  the  methods  of  examining  and  measuring  a  deformed 
pelvis. 
If  from  the  history  anything  can  be  elicited  upon  careful  questioning 
that  would  lead  you  to  suspect  a  pelvic  deformity,  a  careful  examination 
should  be  made  at  least  three  or  four  months  before  labor  occurs. 


*  Alcohol., 

aiJ 

Liq.  plumbi  subacetat., 

5iJ 

Aqutu, 

q.  s.  ad  Oj  ; 

Sig.  External  use. 

124  ANOMALIES   OF   THE   PELVIS   IN   LABOR. 

Inspection^  with  the  woman  standing,  should  first  be  resorted  to.  This 
shows  us  her  height,  and  at  the  same  time,  if  the  deformity  be  exces- 
sive, it  is  often  visible.  Tlie  condition  of  symmetry  of  the  sides  is  no- 
ticed ;  the  limbs,  whether  curved  or  straight,  are  observed.  We  then  ex- 
amine the  spine  for  curvatures,  and  feel  if  the  apex  of  the  sacrum  is  pushed 
inward.  We  next  take  the  external  measurements,  and  for  this  purpose 
a  pelvimeter  (preferably  Baudelocques)  or  a  pair  of  calipers  is  needed. 
After  this  has  been  done  both  vaginal  and  rectal  examinations  should  be 
made — the  former  for  the  purpose  of  determining  the  most  important 
of  all  diameters,  the  true  conjugate ;  the  latter  for  the  purpose  of  ex- 
ploration. 

Give  the  points  between  which  the  external  measurements  are 
taken,  and  the  average  lengths  of  these  measurements  in  a 
normal  pelvis. 

The  measurements  given  are  those  which  are  considered  of  importance 
and  are  in  general  use  : 

From  the  anterior  superior  iliac  spine  of  one  side  to  the 

opposite 9J-10V         inches. 

Extreme  divergence  of  the  iliac  crests,  from 11-11 V  " 

From  centre  of  iliac  crest  to  tuberosity  of  ischium     .    .    .  3.51  '' 

From  centre  of  inferior  border  of  symphysis  to  posterior 

iliac  spine  of  one  or  the  other  side      6.60  " 

From  depression  just  above  spine  of  last  lumbar  vertebra 

to  middle  of  symphj'sis  pubis  (external  conjugate)   .  7.75-8        ** 

The  first  three  may  be  taken  with  the  woman  lying  on  her  back ;  the 
last  two  are  taken  on  the  side. 

How  is  the  internal  diagonal  or  the  true  conjugate  determined  ? 

For  the  purpose  of  taking  this  most  important  measurement  luuner- 
ous  instruments  have  been  devised  ;  but  none  are  as  satisf;\ctory  as  the 
index  and  second  fingers  of  the  right  hand.  With  the  woman  in  the 
dorsal  p(jsition  these  two  fingers  are  intr(jduced  in  an  upward  and  back- 
ward direction  until  the  sacro-vertebral  angle  is  reached.  If  a  deformitv 
be  i)resent,  this  will  not  be  difficult.  The  wrist  is  then  elevated  until  the 
finger  presses  tightly  upon  the  inferior  border  of  the  symphysis.  The  tip 
of  the  index  finger  of  the  left  hand  is  now  placed  ui>oii  the  right  finuer, 
just  under  the  symphysis;  they  are  then  removed,  and  the  distance  fnmi 
the  tip  of  the  second  finger,  which  has  been  in  contact  with  the  sacro- 
vertebral  angle,  to  the  index  of  the  left  hand  is  measured.  .This  gives 
us  the  sacro-snbpubic  diameter,  from  which  the  height  of  the  pubic  arch 
must  be  deducted.  As  a  rule,  this  is  about  l  of  an  inch,  which  is  to  be 
subtracted  from  the  measurement.  However,  with  a  broad  synqdiysis  it 
will  be  necessary  to  deduct  :1  of  an  inch.  Wlien  no  promontory  can  be 
Iclt  the  inference  is  that  labor  nuiy  take  place  at  term,  althouiih  ju'lvic 
deformity  may  be  present,  and  still  we  are  unable  to  feel  this  angle. 


MALFORMATIONS. 


125 


Fig 


What  other  points  should  be  determined  in  making  the  internal 
examination  ? 

The  curve  of  the  pubic  arch,  which  is  of  considerable  importance  in 
recognizing  a  ''masculine  "  pelvis.  Then  by  passing  the  fingers  to  either 
side  we  notice  whether  or  not  the  same  amount  of  space  exists  on  each 
side  of  the  sacrum.  The  curve  of  this  bone  must  also  be  determined. 
In  a  rachitic  pelvis  it  may  be  almost  flat. 

How  may  pelvic  deformities  be  classified? 

I  As  those  aff'ecting  the  entire  pelvis,  j  J^^sto-major, 
^  ^        '  ( J  usto-mmor. 

11.  Those  affecting  certain 
portions  of  the  pelvis,  under 
which  are  classified  the  de- 
formities due  to  disease — 
rachitis,  osteomalacia,  hip  dis- 
ease, etc. 


Describe  the  justo-major 
pelvis. 

It  is  one  in  which  all  the 
diameters  are  equally  en- 
larged. This  form  of  pelvis, 
as  a  rule,  is  not  diagnosed, 
as  little  if  any  difficulty  during 
parturition  occurs  with  this 
class  of  deformity.  The  labor 
is  generally  rapid,  and  may 
even  be  precipitate.  There 
is  likely  to  be  some  little  in- 
crease in  the  irritability  of 
the  bladder  and  rectum  dur- 
ing pregnancy,  as  the  uterus 
descends  farther  into  the  true 
pelvis,  and  therefore  more 
pressure  is  extended  upon 
these  parts. 

In  what  class  of  people  is 
the  justo-minor  pelvis 
most  frequently  found  ? 
Describe  it. 

Usually  in  dwarfs,  although 
it  is  occasionally  met  with  in 
well-developed  women.  It  is 
caused  by  an  arrest  in  growth, 
and  in  these  cases  all  the  di- 
ameters, though  in  proportion  to  one  another,  are  shortened,  sometimes 


Method  of  Ascertaining  the  Internal  Conjugate 
Diameter. 


126  ANOMALIES   OF   THE   PELVIS   IN    LABOR. 

as  much  as  an  inch  or  more.  Some  authors  speak  of  the  infantile  and 
undeveloped  pelvis  as  differing  from  the  justo-minor,  but  it  seems  as 
though  they  might  both  be  classified  with  the  above,  as  the  diameters 
are  in  proportion,  though  all  very  markedly  shortened. 

The  diagnosis  of  these  cases  is  often  not  made  until  labor  has  begun, 
and  if  the  amount  of  contraction  be  excessive  the  prognosis  is  naturally 
very  grave. 

What  is  the  so-called  masculine  pelvis  ?  and  how  is  the  deform- 
ity produced? 

It  is  a  deep  pelvis,  narrowed  at  its  outlet  by  the  close  proximity  of  the 
ischial  tuberosities,  and  hence  called  a  funnel-shaped  pelvis.  The  true 
conjugate  may  be  normal  or  even  increased  in  length.  The  pubic  arch  is 
considerably  narrowed. 

Which  is  the  most  common  variety  of  contracted  pelvis  ? 

The  flattened,  or  that  in  which  the  antero-posterior  diameter  at  the 
brim  is  shortened.  This  deformity  also  occurs  in  rachitic  pelves,  but  is 
frequently  found  unassociated  with  any  disease  of  the  bones.  It  is  pro- 
duced by  a  jutting  forward  and  sliding  down  into  the  pelvis  of  the  sacrum, 
and  is  found  chiefly  among  the  poorer  classes,  who  in  early  life  have  car- 
ried heavy  weights  and  done  hard  work  before  ossification  of  the  pelvic 
bones  has  been  completed.  Though  the  conjugate  diameter  may  be  con- 
siderably narrowed,  the  transverse  remains  about  normal ;  and  from  this 
fact  the  differential  diagnosis  between  the  simple  flattened  and  the  rach- 
itic i)elvis  may  be  made,  for  in  the  latter,  though  the  true  conjugate  be 
but  slightly  shortened,  the  transverse  is  very  frequently  increased  in 
length. 

Describe  the  rachitic  pelvis. 

This  disease,  rachitis,  occurring  early  in  life,  and  producing  as  it  does  a 
shortening  and  arrest  in  development  of  the  bones,  may  give  rise  to  the 
production  of  many  different  deformities,  depending  upon  the  influence 
of  the  external  causes ;  for  the  affection  in  itself  does  not  cause  deform- 
ity, but  renders  the  bones  so  flexible  that  they  are  easily  moulded.  The 
most  common  variety  of  rachitic  pelvis  is  the  flattened.  When  this  is 
associated  with  a  backward  i)r(jjection  of  the  sym])hysis  pubis  and  a 
bulging  of  the  iliac  bones,  we  have  the  "figure-of-eight"  deformity 
(Fig.  34).  In  the  flattened  variety  the  sacrum  is  short,  may  be  flat  or 
even  convex,  is  depressed,  and  tipped  forward  on  its  transverse  axis. 
The  measurement  between  the  anterior  sui)erior  iliac  spines  is  longer 
than  between  the  crests,  just  contrary  to  what  it  should  be.  The  pubic 
arch  is  increased  and  the  ischial  tuberosities  sei)arated  more  than  normal. 
The  diameters  at  the  outUit  may  be  ncnirly  normal  or  increased,  and  the 
whole  [)elvis  is  shallow.  Add  to  the  above  a  })ackward  depression  of  the 
symphysis,  and  the  "figure-of-eight"   detbrmity  is  caused.      Rachitic 


MA  LFORMATIOXS. 


127 


women  are,  as  a  nile,  undersized,  with  short,  curved  Hmbs  and  large, 
prominent  hips.     There  is  often  present  some  spinal  curvature,  and  they 

Fig.  34. 


Rachitic  Pelvis. 

usually  have  a  peculiar  gait.     The  head  is  large  and  square  and  the  fore- 
head prominent. 

Describe  the  osteomalacic  pelvis. 

Osteomalacia,  being  a  disease  of  adult  life  and  occurring  after  the 
complete  development  of  the  bones,  the  deformities  caused  by  it  differ 

Fig.  35. 


Osteomalacic  Pelvis. 


markedly  from  those  due  to  rachitis.     As  the  pelvic  bones  become  soft- 
ened the  weight  of  the  body  above  and  the  upward  pressure  of  the 


128  ANOMALIES   OF   THE   PELVIS   IN   LABOR. 

femora  from  below  cause  the  deformitj'.  The  sacrum  is  depressed  and 
becomes  greatly  curved,  so  that  the  lower  and  upper  pai-ts  approach 
each  other.  At  the  same  time,  this  allows  the  lumbar  vertebrae  to  de- 
scend and  form  a  projection,  narrowing  the  superior  strait.  The  cotyloid 
cavities  are  pushed  upward  and  inward  by  the  femora,  and  thus  both 
oblique  diameters  are  shortened.  The  tuberosities  of  the  ischia  approach 
each  other,  so  that  the  transverse  diameter  at  the  outlet  is  diminished 
and  the  rami  of  the  pubic  bones  come  nearly  in  contact,  leaving  only  a 
deep  fissure  in  place  of  the  arch  (Fig.  35). 

What  is  Nagele's  pelvis? 
This  is  an  extremely  rare  variety  of  pelvic  deformity  which  received 

its  name  from  the  complete  descrip- 
FiG.  36.  tion  given  of  it  by  N^agele.     It  is 

the  obliquely  oval  pelvis  caused  by 
an  ankylosis  of  one  of  the  sacro- 
iliac articulations  and  a  lack  of  de- 
velopment of  the  half  of  the  sa- 
crum and  the  ilium  on  this  side. 
The  sacrum  is  pushed  over  toward 
the  ankylosed  side,  and  the  sym- 
physis pubis  drawn  toward  the  op- 
posite side.  The  oblique  diameter, 
which  is  narrowed,  is  the  one  ex- 
tending from  the  normal  sacro-iliac 
synchondrosis     (Fig.    36)    to    the 

ilio-pectineal  eminence  on  the  af- 

Na^et^Tpeivis.  fccted  side. 

Describe  the  transversely-contracted  pelvis. 

This  is  called  the  Roberts'  pelvis,  as  it  was  first  described  by  this 
writer.  It  is  characterized  by  comi)lete  ankylosis  of  both  the  sacro-iliac 
articulations.  The  sacrum  is  also  depressed  in  the  pelvis,  and  the  iliac 
bones  flattened,  so  that  there  is  a  marked  contraction  both  at  the  brim 
and  outlet.  It  is  an  extremely  rare  deformity,  but  H  cases  having  been 
recorded.     In  6  the  Caesarean  section  was  done ;  in  2,  craniotomy. 

Describe  the  pelvic  deformity  caused  by  scoliosis  combined  with 
rachitis. 
Scoliosis  alone  rarely  causes  sufficient  deformity  to  influence  labor  to 
any  great  extent.  Hf)Wover,  when  complicatiuiz  rickets,  the  extent  and 
severity  of  the  malformation  are  increased.  The  internal  conjugate  is 
shortened,  as  well  as  the  oblique  diameter  at  the  outlet,  and  there  is  a 
transverse  narrowing  at  the  superior  strait.  There  is  also  an  inclination 
of  the  sacrum  on  the  side  of  the  lumbar  scoliosis. 

What  is  kyphosis?  and  what  influence  has  it  upon  the  pelvis? 

It  is  the  backward  deviation  of  the  vertebral  column,  and  may  be  con- 


MALFORMATIONS.  129 

fined  to  one  region  of  the  spine  or  involve  nearly  its  whole  length.  It 
may  be  caused  bj"  rickets  or  be  due  to  some  local  disease,  such  as  caries. 
The  curvature  has  a  tendency  to  draw  the  upper  part  of  the  sacrum 
upward  and  backward,  at  the  same  time  throwing  forward  its  lower  por- 
tion. The  ischial  tuberosities  are  brought  nearer  together  and  the  jnibic 
arch  narrowed :  the  result  is  a  deformity  in  which  the  antero-posterior 
diameter  at  the  brim  is  lengthened,  while  that  at  the  outlet,  as  well  as 
the  transverse;  is  shortened.  If  kyphosis  exists  with  rickets,  the  de- 
formity is  evel  more  marked  and  complex. 

State   the    character   of  the    deformity  caused  by  spondylolis- 
thesis and  spondylozemia. 

It  is  a  narrowing  at  the  brim,  sometimes  to  a  very  great  extent.  The 
cause  lies  not  in  the  pelvis  itself,  but  by  the  sinking  of  the  lower  lumbar 
vertebrae  into  the  pelvic  cavity ;  therefore  the  narrowing  is  not  of  the 
true  conjugate,  which  remains  normal  or  possibly  lengthened,  but  rather 
a  blocking  up  of  the  pelvic  inlet.  The  cause  is  either  a  dislocation  for- 
ward of  the  vertebrge,  owing  perhaps  to  disease  of  the  articulations,  or 
the  condition  known  as  spond.ylozemia,  in  which  the  bodies  of  the  lower 
lumbar  vertebrae  are  destroyed  by  caries,  allowing  those  above  to  sink 
downward  and  forward.  The  deformity  is  practically  the  same  in  either 
case,  though  the  cause  is  very  diiferent. 

What  other   conditions   besides   those   enumerated   above  may 
cause  deformed  pelves? 

(1)  Luxations  of  either  one  or  both  femurs,  whether  congenital  or 
acquired,  may  cause  deformity.  If  but  one  side  is  aifected,  the  half  of 
the  pelvis  corresponding  to  the  injury  is  less  developed,  and  the  pelvis  is 
inchned  to  this  side.  The  one  obhque  diameter  is  diminished.  If  dis- 
location be  present  on  both  sides,  the  iliac  fossas  are  pushed  closer  to- 
gether, with  the  result  of  narrowing  the  transverse  diameter  of  the  cav- 
ity and  increasing  that  of  the  outlet.  With  this  deformity  there  is  also 
an  alteration  in  the  planes  of  the  pelvis. 

(2)  Tumors  growing  upon  the  bones  and  obstructing  the  cavity  are  of 
very  rare  occurrence. 

Describe  the  methods  of  diagnosing  a  contracted  pelvis. 

In  an  equally-contracted  pelvis  the  external  measurenients  will  usually 
show  the  condition  of  affairs,  and  by  a  digital  examination  a  confirma- 
tion of  the  diagnosis  is  readily  made.  In  the  flattened  pelvis  we  get  the 
shortened  internal  conjugate,  with  perhaps  measurements  externally 
which  are  normal  or  nearly  so.  This  is  not  the  case  in  the  rachitic  pel- 
vis, where  the  external  measurements  are  apt  to  be  considerably  altered, 
as  stated  above.  The  transversely-contracted  pelvis  is  determined  by 
finding  a  shortening  of  the  following  diameters :  between  the  crests  rind 
anterior  superior  spines  of  the  ilia  and  between  the  ischiatic  tuberosities. 
Cases  due  to  or  associated  with  spinal  curvatures  may  be  diagnosed  by 
the  history  of  the  case  and  an  examination  of  this  condition.     The  posi- 

9— Obs. 


130  ANOMALIES   OF   THE   PELVIS    IN    LABOR. 

tive  diagnosis  of  the  obliquely-contracted  pelvis  is  made  by  letting  fall 
two  plumb-lines  with  the  woman  in  the  erect  position — one  from  the 
symphysis  pubis,  and  one  from  the  sacral  spines.  In  a  normal  pelvis 
these  will  fall  in  the  same  plane,  while  in  one  obliquely  contracted  they 
will  deviate  considerably. 

What  effects  upon  pregnancy  and  labor  has  a  contracted  pelvis  ? 

Many  times  the  direct  cause  of  an  abortion  or  miscarriage  may  be 
attributed  to  pelvic  deformity.  In  case  this  does  not  occur  and  the  preg- 
nancy goes  on  to  term,  we  find  the  fundus  uteri  higher  than  it  should  be 
at  the  period  of  the  pregnancy,  the  abdominal  walls  hang  forward,  and 
abnormal  presentations  of  the  foetus  are  much  more  apt  to  be  present 
than  is  the  case  in  normal  pelves,  the  greater  frequency  of  face  and 
shoulder  presentations  being  especially  marked.  Some  of  the  disorders 
of  pregnancy  are  apt  to  be  much  aggravated  by  deformities.  This  is 
especially  true  of  the  dyspnoea  and  circulatory  disturbances.  In  propor- 
tion to  tiie  amount  of  deformity  are  the  risks  to  both  mother  and  child, 
and  the  same  may  be  said  in  regard  to  the  alterations  in  the  character 
of  the  labor.  The  pains  are  increased  in  intensity,  depending  upon  the 
amount  of  resistance  to  be  overcome.  Labor  is  prolonged,  and  before 
its  completion  the  character  of  the  contractions  usually  changes,  and 
from  being  severe,  frequent,  and  regular  they  become  infrequent  and 
irregular,  finally  ceasing  altogether.  The  os  dilates  very  slowly,  owing 
to  the  weak  pains  and  the  fact  that  in  such  cases  early  ru})ture  of  the 
membrane  is  likely  to  take  place.  Then  also  the  cervix  is  apt  to  be 
tliick,  as  the  head  has  been  i)revented  from  making  any  pressure  upon  it 
by  being  held  above  the  pelvic  brim  by  the  contraction. 

What  can  you  say  of  the  prognosis  to  both  mother  and  child  in 
pelvic  deformities  ? 

In  every  case  both  the  mother  and  child  are  exposed  to  more  dangers 
than  in  delivery  through  a  normal  pelvis,  but  to  make  a  correct  prognosis 
in  every  case  is  out  of  the  question.  We  must  be  very  guarded  in  our 
prognosis,  and  governed  entirely  by  the  character  and  amount  of  the 
deformity,  the  presentation  of  the  foetus,  and  the  period  of  pregnancy 
at  which  the  case  comes  under  observation.  The  greatest  danger  to  the 
mother  is  from  injury  to  the  soft  parts  and  occasionally  to  the  pelvic 
joints.  Then  in  those  cases  where  operative  interference  becomes  neces- 
sary the  prognosis  is  graver.  To  the  child  the  risks  are  from  prolonged 
compression,  injuries  to  the  head,  body,  and  limbs  during  birth,  and  the 
greater  frequency  with  which  prolapse  of  the  funis  occurs. 

Describe  the  mechanism  of  delivery  in  vertex  presentations. 

(1)  In  generally  and  equally  contracted  pelves  the  occiput  is  the  first 
part  of  the  head  to  engage.  This  becomes  jammed  down,  so  that  the 
posterior  fontanelle  lies  low  in  the  pelvis,  while  the  anterior  is  too  high 
up  to  be  within  reach.     The  resistance  now  begins.     If  the  contraction 


MALFORMATIONS.  131 

is  not  too  great,  delivery  will  be  accomplished  in  the  usual  way  with  a 
markedly  moulded  head  or  craniotomy  may  become  necessary. 

(2)  In  a  flattened  pelvis  the  head  enters  the  pelvis  with  it.s  biparietal 
diameter  lying  in  the  antero-posterior  diameter  of  the  brim  :  it  becomes 
well  flexed,  so  that  the  posterior  fontanelle  comes  to  lie  almost  in  the 
centre  of  the  pelvis.  In  this  way  descent  occurs  until  the  pelvic  floor  js 
reached,  when  internal  rotation  takes  place  and  delivery  is  completed  in 
the  natural  way.  The  above  occurs  only  in  those  cases  in  which  the  con- 
traction is  not  great  and  the  antero-posterior  diameter  of  the  brim  will 
allow  of  the  engagement  of  the  biparietal  diameter  of  the  foetal  head. 
When  the  contraction  is  too  great  to  allow  of  engagement,  flexion  does 
not  occur  above  the  pelvis,  the  bitemporal  diameter  engages,  the  head 
extends,  and  a  brow  or  face  presentation  results. 

(3)  In  the  obliqueb'-contracted  pelvis,  if  the  amount  of  obliquity  and 
the  contraction  be  not  too  great,  the  head  enters  the  pelvis  in  the  longer 
obhque  diameter,  well  flexed.  Descent  in  this  same  diameter  continues 
until  the  pelvic  floor  is  reached,  when  the  labor  terminates  in  the  natural 
way. 

What  can  you  say  of  the  treatment  in  pelvic  deformities  ? 

The  treatment  resolves  itself  into  one  of  flve  courses — forceps,  version, 
the  induction  of  premature  labor,  craniotomy  or  embryotomy,  and  the 
Caesarean  section.  Unfortunately,  no  hard-and-fast  rules  applicable  to 
every  case  can  be  made,  and  the  course  pursued  must  depend  entirely 
upon  the  circumstances  under  which  the  case  is  seen.  Most  authors 
agree  that  a  live  child  at  full  term  cannot  pass  through  a  pelvis  which 
measures  less  than  3  inches  in  the  internal  conjugate  and  4  in  the  trans- 
verse, unless  it  be  unusually  small.  If  the  case  has  been  under  observa- 
tion from  the  beginning  of  pregnancy,  and  careful  pelvic  measurements 
be  taken,  and  if  the  internal  conjugate  is  not  below  2-9-  or  2|  inches,  we 
should  try  and  carry  the  pregnancy  to  a  period  when  a  living  child  might 
be  born,  and  then  induce  labor.  Nature  may  complete  the  delivery  after 
the  pains  have  begun ;  and  if  not,  delivery  by  the  forceps  is  much  more 
likely  to  give  a  living  child,  owing  to  the  softness  of  the  foetal  bones  and 
the  readiness  with  which  the  head  may  be  moulded.  The  following 
table,  given  by  Kiwisch  and  copied  from  Playfair,  may  aid  very  ma- 
terially in  concluding  the  proper  time  at  which  labor  should  be  induced : 

Inches.        Lines. 

Wlien  the  sacro-pubic  diameter  is  2  and  6   or  7,  induce  labor  at  the  30th  week. 

31st  " 

"  "  32d  " 

"  "  33d  " 

33d  " 

34th  " 

35th  " 

"  "         36th  " 


2 

u 

8 

"     9, 

2 

11 

10 

"  11, 

3 

3 

1, 

3 

u 

2 

or  3, 

3 

a 

4 

"     5, 

3 

11 

5 

"     6, 

132  ANOMALIES   OF   THE   FCETUS. 

Barnes  says — and  his  opinion  is  corroborated  by  many  other  authors — 
that  either  version  or  the  forceps  is  appHcable  to  the  pelvis  of  3.1  to  3.5 
inches  in  the  internal  conjugate.  Many  objections  have  been  raised  to 
the  use  of  the  forceps,  especially  by  the  German  obstetricians,  some  of 
which  are  the  difficulties  of  introducing  the  blades  and  the  danger  of 
causing  injury  to  the  maternal  structures.  If  the  head  is  seized  by  the 
occiput  and  forehead,  it  is  maintained  that  their  compressive  action  will 
decrease  its  long  diameter  and  increase  the  transverse.  All  these  objec- 
tions are  certainly  open  to  criticism. 

Many  believe  it  much  easier  to  pull  the  after-coming  head  through  a 
contracted  brim  than  to  draw  the  before-coming  head  down  by  the  for- 
ceps, and  therefore  favor  version.  It  is  certainly  true  that  version  will 
succeed  where  the  forceps  have  failed.  In  pelves  between  3  and  3t 
inches  version  should  be  attempted.  Between  3^  and  3j  either  is  per- 
fectly justifiable.  Above  3*  the  forceps  should  be  tried,  and  if  without 
success  version  may  be  done.  In  all  pelves  below  3  inches  craniotomy 
or  the  Caesarean  section  must  be  resorted  to.  The  latter  is  certainly  not 
indicated  in  pelves  measuring  more  than  2|  inches  in  the  internal  con- 
jugate, unless  the  child  be  unusually  large. 

ANOMALIES  OF  THE  FCETUS. 

PLURAL  BIRTHS. 

State  the  causes  of  dystocia  in  multiple  pregnancies. 

Inertia  uteri,  owing  to  the  excessive  distension  of  the  organ,  the  pres- 
entation of  parts  of  both  children  simultaneously,  and  the  interlocking 
of  the  two  heads  in  cases  where  one  child  presents  by  the  vertex  and 
the  other  by  the  breech. 

Does  the  management  of  a  normal  twin  labor  differ  from  that 
of  a  single  labor  ? 

It  does  not.  As  soon  as  the  first  child  is  born  and  its  cord  tied  and 
ciit  the  child  should  be  removed.  Then  we  should  wait  a  short  time  for 
the  uterine  contractions  to  recur.  If  they  do  not  come  on  within  a  few 
minutes,  the  membranes  surrounding  the  second  foetus  ought  to  be  rup- 
tured and  gentle  friction  made  over  the  fundus.  If  this  does  not  pro- 
duce contractions,  the  forceps  may  be  applied,  provided  the  head  has 
entered  the  pelvis,  or  a  version  may  be  done  if  this  is  not  the  case. 
Either  will  be  comparatively  easy,  as  the  parturient  canal  has  been  well 
dilated  by  the  birth  of  the  first  child. 

How  would  you  treat  a  case  in  which  both  heads  were  found 
presenting  ? 

By  introducing  the  hand  in  the  vagina  and  the  fingers  into  the  uterus 
an  attempt  may  be  made  to  push  one  child  up  out  of  the  way.     The 


FCKTAL    DYSTOCIA. 


133 


forceps  are  then  applied  to  the  other,  that  it  maybe  "engaged,"  and 
thus  prevent  a  reeiuTence  of  the  complication. 

If  both  heads  have  entered  the  pelvis — and  such  cases  are  recorded — 
it  will  probably  be  impossible  to  push  one  back  into  the  uterus;  in  which 
case  the  forceps  might  succeed  in  delivering,  though  probably  perfora- 
tion would  be  necessary. 

In  what  class  of  cases  does  interlocking  of  the  heads  occur  ? 

In  those  cases  in  which  one  child  presents  by  the  breech  and  the  other 
by  the  vertex  (Fig. 


_  ot). 
The  former  is  born  as 
far  as  the  head,  when 
delay  occurs.  An  exam- 
ination now  reveals  the 
presence  of  the  head  of 
the  second  fcetus  within 
or  at  the  brim  of  the 
pelvis,  and  the  under 
part  of  the  chins  of  both 
infants  in  contact.  We 
must  try  to  push  the 
second  child  back,  as  in 
the  case  described  above ; 
or,  if  this  is  not  possible, 
the  forceps  may  be  ap- 
plied and  an  attempt 
made  to  draw  the  head 
past  the  body  of  the  first 
child.  If  neither  means 
proves  successful,  decapi- 
tation of  the  first  child 
must  be  resorted  to.  This 
can  be  done  by  the  scissors 
or  ecraseur;  the  body  is 
then  delivered,  and  after- 
ward the  second  head  re- 
moved with  the  forceps. 


Fig.  37. 


Locked  Twins. 


FCE3TAL  DYSTOCIA. 

What  are   the   simplest  forms   of  foetal  dystocia?    and  under 
what  circumstances  are  they  found? 

(1)  An  exceedingly  large  child  ;  (2)  premature  ossification  of  the  bones 
of  the  skull.  These  may  both  be  met  with  in  women  marrying  late  in 
life,  though  the  excessive  sign  of  the  child  is  the  more  frequent  cause  of 
dystocia  under  such  circumstances.  Our  first  recourse  is  to  the  forceps, 
and  if  delivery  cannot  be  accomplished  craniotomy  must  be  done. 


134  ANOIMALTES   OF   THE   FOKTTJS. 

When,  as  occasionally  happens,  the  delay  is  of  the  shoulders  and 
occurs  after  the  birth  of  the  head,  traction  may  be  made  by  drawing  on 
the  head  or  by  the  introduction  of  the  fingers  in  the  axillae,  and  will 
usually  be  successful.  If  not,  the  arms,  one  after  the  other,  must  be 
disengaged  and  drawn  down. 

HYDROCEPHALUS.   ENCEPHALOCELE. 
State  the  method  of  diagnosing  intra-uterine  hydrocephalus. 

Abdominal  palpation  will  often  lead  us  to  suspect  the  condition,  if  it 
be  present,  on  account  of  the  disproportion  between  the  head  and  breech. 
On  vaginal  examination  after  the  rupture  of  the  membranes,  the  head 
is  felt  as  a  large  fluctuating  mass  with  enormous  fontanelles  and  broadly- 
separated  sutures.  The  bones  are  apt  to  be  very  thin,  and  for  this 
reason  the  head  has  been  mistaken  for  a  second  bag  of  waters. 

"What  can  you  say  of  the  prognosis  and  treatment  in  these 
cases  ? 

The  prognosis  both  for  mother  and  child  is  very  grave.  The  dangers 
to  the  mother  are  from  rupture  of  the  uterus  and  injury  to  the  soft 
parts. 

The  treatment  varies  according  to  the  presentation.  If  the  disease  is 
but  slightly  developed,  it  may  be  possible  to  deliver  by  the  forceps  in 
vertex  cases ;  and  under  such  favorable  circumstances  there  is  likely  to 
be  little  if  any  difficulty  in  delivering  the  head,  provided  the  child  pre- 
sents by  the  breech.  In  most  cases,  however,  craniotomy  will  be  neces- 
sary. Of  course  in  breech  cases  the  perforation  must  be  made  through 
the  occipital  bone. 

Name  the  congenital  tumors  of  the  skull  whicli  may  cause 
dystocia. 

Meningocele,  which  is  a  tumor  over  some  point  of  the  skull  made  up 
of  a  portion  of  the  meninges  protruding  through  a  congenital  opening 
of  the  bones.     This  rarely,  if  ever,  causes  a  delaj^ed  labor. 

Encephalocele  is  the  same  as  the  above,  excepting  that  some  brain-sub- 
stance in  addition  to  the  meninges  is  contained  within  the  tumor. 

Hijdro-encephalocele  contains  meninges,  brain-substance,  and  _  fluid. 
This  is  the  only  form  of  the  three  which  might  cause  delay  in  the 
labor.  If  .so,  it  should  be  punctured  and  the  fluid  evacuated.  The 
further  progress  of  the  labor  will  not  be  materially  influenced. 

Dropsical  effusions  in  the  thorax  or  abdominal  cavity,  and  malignant 
tumors  of  the  liver,  spleen,  or  kidneys,  have  occurred  with  resulting 
delay,  but  these  cases  are  extremely  rare. 

MONSTROSITIES. 

What  is  an  anencephalic  monster? 
One  devoid  of  a  brain.     The  head  is  extremely  small  and  rests  directly 


HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR.    135 

upon  the  shoulders ;  the  eyes  protrude  and  look  almost  in  an  upward 
direction ;  the  tongue  most  frequently'  protrudes  from  the  moutli. 

What  forms  of  double  monsters  are  described  ? 

(1)  Two  complete  foetuses,  normally  constituted,  but  united  at  some 
point.  The  fusion  may  be  either  back  to  back,  in  which  case  it  is  at  the 
sacrums;  the  two  heads  may  be  united ;  or  the  union  may  take  i)lace  in 
front,  when  it  generally  extends  from  the  umbiHcus  to  the  upper  part  of 
the  thorax. 

(2)  A  single  body  with  two  heads.  These  are  made  up  of  two  bodies 
also,  but  they  are  so  fused  that  no  evidences  manil'est  themselves  exter- 
nally. 

The  progress  and  mechanism  of  dehvery  in  this  class  of  cases  must 
necessarily  vary  considerably,  depending  upon  the  form  of  the  monster 
and  its  presentation. 

If  both  heads  present,  one  head  may  be  born,  then  the  other,  and 
afterward  the  bodies,  or  mutilation  of  the  infants  must  be  resorted  to. 

In  case  the  two  heads  attempt  to  enter  the  pelvis  at  tbe  same  time,  and 
one  cannot  be  pushed  back,  craniotomy  nuist  be  done,  unless  the  labor  is 
a  premature  one  or  the  heads  are  very  small. 


CHAPTER   VI. 
HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

HEMORRHAGES  DURING  AND   AFTER  DELIVERY. 

Do  severe  hemorrhages  ever  occur  during  labor  ?  and  what  is 
the  source  of  the  blood  if  hemorrhage  does  occur  at  this 
time  ? 

They  do  not,  unless  from  placenta  praevia  or  a  low  implantation  of  the 
placenta.  There  may  be  a  little  flood  of  blood  from  lacerations  of  the 
cervix  or  the  os.  These  cease  spontaneously,  and  only  occur  while  dilata- 
tion is  going  on  or  just  as  the  second  stage  is  reached. 

Or  some  hemorrhage  may  occur  from  abrasions  or  tears  of  the  vaginal 
mucous  membrane  or  perineum.  These  take  place  as  the  head  passes 
through  the  pelvis  or  escapes  from  the  vulva,  and  are  ver}^  rarely  seri- 
ous. It  occasionally  happens  in  extensive  injuries  or  lacerations  that 
some  large  vessel  is  ruptured,  but  the  position  is  such  that  clamping 
and  hgation,  if  necessary,  may  be  easily  done,  so  that  little  if  any  harm 
ever  results. 

What  is  a  post-partum  hemorrhage?  and  what  three  varieties 
are  met  with  ? 

A  post-partum  hemorrhage  is  a  hemorrhage  occurring  from  the  uterus 


136     HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

after  the  birth  of  the  child.  This  may  be  ( 1 )  immediately  after  the 
child  is  born,  but  before  the  third  stage  is  completed  ;  (2)  after  the  birth 
of  the  placenta;  (3)  some  hours  after  labor  is  completed.  This  last 
variety  is  called  "  secondar}^  post-partum  hemorrhage." 

An  alarming  flow  of  blood  may  take  place  after  the  child  is  born  from 
a  badly-lacerated  cervix,  cases  even  occurring  where  the  circular  artery 
of  this  part  of  the  uterus  has  been  ruptured.  These  are  not  true  post- 
partum hemorrhages,  though  unless  care  is  taken  they  might  easily  be 
thought  such. 

A  vaginal  examination  reveals  the  condition,  and  the  treatment  con- 
sists in  passing  a  wire  suture  through  the  cervix,  so  as  to  close  the  rent 
and  thus  check  the  flooding. 

State  the  frequency  and  causes  of  post-partum  hemorrhage. 

It  is  an  extremely  frequent  complication  of  labor  unless  the  case  be 
managed  properly  throughout,  under  which  circumstances  it  rarely 
occurs. 

The  one  cause  is  uterine  inertia.  This  may  be  brought  about  or  pro- 
duced in  many  ways.  One  very  frequent  cause  of  inertia  is  over-disten- 
sion of  the  organ  from  twins  or  hydramnion.  Prolonged  labors,  from 
exhausting  the  muscles ;  precipitate  labors,  in  which  the  uterus  is  so 
rapidly  emptied  that  it  does  not  contract;  and  rapid  forceps  deliveries, — 
bring  about  the  same  result.  A  debilitated  or  exhausted  condition  of  the 
mother  from  albuminuria,  anaemia,  or  other  diseases,  and  emotional 
causes  in  neurotic  women,  are  also  productive  of  the  accident. 

The  causes  of  secondary  hemorrhages  may  be  any  of  the  above,  and 
in  addition  the  retention  within  the  uterus  of  portions  of  the  placenta, 
the  membrane,  or  large  blood-clots.  Any  exertion,  such  as  turning 
quickly  upon  the  side  or  rising  suddenly  in  bed,  may  cause  it,  as  well  as 
the  free  use  of  cardiac  stimulants.  Local  conditions,  in  the  way  of  dis- 
tended bladder  or  full  rectum,  have  also  caused  severe  hemorrhage,  as 
also  the  different  forms  of  displacements,  especially  retroflexion. 

What  are  the  symptoms  ? 

The  flow  of  blood  may  occur  suddenly  and  with  a  profuse  gush,  or 
may  begin  as  a  slight  trickling,  which  continues  onl}'  as  such  or  later 
becomes  more  profuse.  This  may  be  the  only  symptom  if  the  hemor- 
rhage is  immediately  checked.  If  not.  all  the  signs  accompanying  the 
loss  of  blood  follow.  The  face  becomes  pale  and  anxious,  the  extremities 
cold,  the  pulse  rapid  and  feeble  ;  blindness  and  possibly  sync()])e  occur, 
or  perhaps  extreme  restlessness  supervenes  and  the  i)atient  throws  her- 
self about  on  the  bed.  The  so-called  "air  hunger"  is  developed,  the 
patient  taking  short,  rapid  respirations  and  crying  for  air;  then  a  con- 
vulsion may  occur,  and  in  this  the  woman  dies. 

In  ca.ses  of  secondary  liemorrhage  we  may  be  deceived  in  looking  on 
the  vulvar  pad  i'or  blood  and  finding  none,  and  so  attribute  the  symptoms 
to  some  other  cause.     The  absence  of  the  flow  is  owing  to  the  formation 


HEMORRHAGES    DURING    AND    AFTER    DELIVERY.       137 

of  a  clot  at  the  cervix,  wliicli  prevents  the  escape  of  the  blood  externally, 
and  the  onl}-  thing  found  on  the  dressing  is  a  little  clear  serum. 

In  an}'  case  an  examination  of  the  abdomen  immediately  reveals  the 
condition.  We  find,  instead  of  the  hard,  rounded  uterus,  a  soft,  flabby- 
feeling  abdomen,  and  are  perhaps  unable  to  map  out  the  uterus,  or,  if 
we  do  make  it  out.  it  is  large-  with  the  fundus  high  up. 

What  is  the  treatment  ? 

The  treatment  should  be — 

(1)  Preventive. — From  the  time  the  head  has  emerged  from  the  vulva 
until  at  least  half  an  hour  or  three-quarters  of  an  hour  after  the  placenta 
has  come  away,  the  hand  should  be  kept  over  the  fundus  of  the  uterus 
to  prevent  its  relaxation.  Then,  as  soon  as  a  careful  examination  of  the 
l^lacenta  and  membranes  shows  them  to  be  intact,  a  full  dose  of  the  fluid 
extract  of  ergot  (3j-.^ij)  should  be  given  as  a  routine  practice  in  every 
case,  and  at  the  end  of  three-quarters  of  an  hour  the  binder  applied. 
The  patient  must  be  moved  carefully  and  gently,  and.  above  all,  kept 
from  any  form  of  excitement. 

If  the  above  is  carefully  carried  out  in  every  case,  a  post-partum  hem- 
orrhage will  be  an  extremely  rare  occurrence. 

(2|  Curative. — Our  energies  are  all  directed  toward  one  thing,  and 
that  is  to  excite  uterine  contractions.  Faihng  in  this,  recourse  must  be 
had  to  the  use  of  styptics.  The  former  is  Nature's  method  of  checking 
and  preventing  uterine  hemorrhage,  and  unless  all  the  reflex  irritabihty 
of  the  organ  is  gone  it  will  be  successful. 

As  soon  as  the  placenta  is  separated  from  the  wall,  which  occurs  dur- 
ing the  last  few  pains,  the  muscular  fibres  contract  firmly,  completely 
closing  the  orifices  of  the  torn  utero-placental  vessels :  thrombi  now 
form  in  these  vessels,  and,  even  though  shght  relaxation  of  the  womb 
does  occur,  no  hemorrhage  results.  Therefore,  if  we  can  bring  about 
this  condition  of  afl"airs  when  it  does  not  take  place,  we  accomplish  what 
Nature  has  neglected  to  do.  If  the  hemorrhage  takes  place  before  the 
birth  of  the  placenta,  sufiicient  friction  over  the  fundus  to  cause  a  con- 
traction and  the  delivery  by  Crede's  method  will  generally  be  immedi- 
ately followed  by  a  cessation  of  the  flow.  However,  we  find  cases  where 
repeated  attempts  at  Crede's  method  of  expression  fail,  and  in  such  cases 
the  secundines  must  be  removed  by  the  introduction  of  the  hand  into 
the  cavity  of  the  uterus.  With  the  umbilical  cord  as  a  guide  we  slowly 
pass  the  hand,  which  has  been  made  thoroughly  aseptic,  into  the  uterus, 
and,  reaching  the  placenta,  carefully  insert  the  fingers  between  it  and 
the  uterine  wall,  and  gently  dissect  it  ofl".  Extreme  care  must  be  taken 
not  to  injure  the  delicate  membrane  lining  the  uterus,  for  it  is  at 
times  difficult  to  distinguish  between  it  and  the  placental  tissue.  A 
thorough  uterine  irrigation  should  follow  any  procedure  of  this  kind. 

If  the  hemorrhage  occurs  after  the  birth  of  the  placenta,  immediately 
attempt  to  excite  contraction  by  fiiction  over  the  fundus,  and  give  the 
patient  a  full  dose  of  ergot,  or,  better  still,   a  hypodermic  of  ergotin. 


138     HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

While  this  is  being  done  the  nurse  or  assistant  should  be  preparing  a  hot 
douche  of  carbolic  acid,  1  :  80,  or  bichloride  of  mercury,  1  :  5000  or  8000, 
at  a  temperature  of  118°  to  120°  F.,  and  with  a  Chamberlin's  tube  an 
intra-uterine  irrigation  is  given.  The  hemorrhage  continuing  after  one 
or  two  pints  have  been  used,  we  should  not  continue  this  longer,  but  re- 
sort to  some  other  method  of  causing  conti-action  ;  and  one  of  the  sim- 
plest and  at  times  most  effective  is  ice.  iV  piece  about  the  size  of  a 
walnut  is  carried  up  into  the  interior  of  the  uterus  and  rubbed  about  its 
wall.  If  the  organ  does  not  respond,  do  not  use  a  second  piece,  but  if  a 
faradic  battery  be  at  hand  use  a  current  with  one  pole  over  tlie  fundus, 
the  other  in  the  uterus.  The  foot  of  the  bed  should  now  be  elevated, 
and  compression  of  the  abdominal  aorta  may  be  tried  before  styptics  are 
used  if  the  hemorrhage  continues.  The  aorta  can  be  distinctly  felt  above 
the  fundus  uteri,  and  may  be  pressed  against  the  vertebral  column  by 
placing  the  side  of  the  hand  erossways  over  it.  This  procedure  is  of 
very  doubtful  utility. 

The  three  styptics  most  commonly  employed  are  vinegar,  the  subsul- 
phate  of  iron  (Monsel's  solution),  and  tincture  of  iodine.  The  first  is 
used  by  soaking  a  cloth  or  piece  of  gauze  in  the  vinegar,  passing  it  up 
into  the  uterus,  and  squeezing  it  out.  The  others  should  be  used  only 
in  solution.  The  strength  of  the  solution  of  the  subsulphate  of  iron  may 
be  about  1  :  4,  and  of  the  iodine  1:2;  but  never  employ  either  unless 
you  are  sure  of  an  avenue  by  which  the  fluid  can  escape.  To  be  positive 
of  this,  pass  two  fingers  through  the  cervix,  so  as  to  keep  it  open,  and 
have  a  hand  placed  over  the  fundus  of  the  uterus. 

Our  methods  must  all  be  supplemented  by  treatment  directed  to  the 
general  condition  of  the  mother.  Hypodermic  injections  of  ether,  whis- 
key, caffeine,  strophanthus,  digitalis,  etc.  may  be  necessary ;  hot  bottles 
should  be  placed  about  the  patient,  the  i)illows  removed  from  under  her 
head,  and  the  extremities  bandaged.  For  this  purpose  ordinary  cloth 
bandages  may  be  used,  being  applied  moderately  tight  from  the  toes  to 
the  pelvis  and  from  the  fingers  to  the  shoulders.  These  may  be  left  on 
until  the  patient  rallies  somewhat. 

Absolute  quiet  must  be  enjoined,  and  the  hand  kept  over  the  fundus 
of  the  uterus  for  several  hours  at  least.  Remove  all  soiled  clothing  from 
about  the  patient  without  moving  her,  and  after  a  few  minutes  give  a 
teaspoonfid  of  brandy  in  liot  water.  If  the  stomach  will  retain  this,  the 
dose  may  be  repeated  every  fifteen  minutes  until  the  heart  begins  to 
respond.  If  it  is  rejected,  hypodermic  and  rectal  stimulation  must  be 
resorted  to.  For  the  latter  8  to  16  ounces  of  liot  water  containing  an 
ounce  of  brandy  may  be  given  through  a  rectal  tube.  At  the  end  of  a 
few  hours  small  quantities  of  beef  juice  or  mutton  broth  will  usually  be 
tolerated  by  the  stomach.  The  patient  should  not  be  disturbed  to  change 
or  remove  the  bed-clothes  for  at  least  fifteen  or  twenty  hours. 

'IMie  treatment  of  secondary  hemorrhage  is  ))racti('ally  the  same  as  that 
for  priniary,  excepting  that  we  must  bear  in  mind  the  fact  that  this  form 
is  generally  caused  by  the  presence  of  some  foreign  body  within  the  ute- 


INVERSION    OF    THE    UTERUS.  139 

rine  cavit.v.  Therefore  our  jBrst  procedure  will  be  to  carefully  remove  this, 
whether  it  be  placental  tissue,  membranes,  or  blood-clots,  by  the  intro- 
duction of  the  hand.  Afterward  a  douche  is  given,  and  as  a  rule  firm 
contraction  results.     Always  see  that  the  bladder  and  bowel  are  empty. 

In  all  cases  of  hemorrhage  the  loss  of  blood  may  be  so  excessive  that 
transfusion  or  infusion  becomes  necessary.  The  method  of  doing  this 
will  be  described  later. 

The  after-treatment  consists  in  the  administration  of  a  full,  nutritious 
diet,  tonics,  and  iron. 

INVERSION  OF  THE  UTERUS. 
What  is  inversion  of  the  uterus  ? 

It  is  the  partial  or  complete  turning  inside  out  of  the  large,  empty 
post-partum  organ.  As  a  nde.  it  begins  as  a  shght  depression  of  the 
fundus,  which  may  remain  so  or  continue  to  sink  until  the  entire  mucous 
coat  is  outside  and  the  peritoneal  inside.  The  former  is  called  partial, 
the  latter  complete,  inversion. 

If  the  condition  is  seen  and  successfully  treated  immediately  after  its  oc- 
currence, it  constitutes  the  so-called  acute  form,  but  if  allowed  to  remain 
in  its  abnormal  condition  and  adhesions  form,  it  becomes  chronic.  Be- 
sides beginning  at  the  fundus,  cases  are  recorded  where  the  inversion  has 
begun  at  the  cervix. 

State  the  causes  of  inversion  of  the  uterus. 

There  are  three  conditions  which  favor  this  accident — namely,  uterine 
inertia,  pressure  from  above,  and  traction  from  below.  Naturally,  a 
combination  of  the  three  might  operate  at  the  same  time,  under  which 
circumstances  the  unfortunate  occurrence  would  very  likely  result. 
When  due  to  accident  the  causes  generally  given  are  traction  on  the  cord 
while  the  placenta  is  still  adherent  to  the  uterine  wall :  a  very  short  cord 
or  one  wound  about  the  body  of  the  infant :  too  rapid  a  delivery  ;  delivery 
in  the  erect  posture  :  and  strong  efforts  at  straining  on  the  part  of  the 
woman. 

Spontaneous  inversions  also  occur.  These  are  due  to  irregular  con- 
tractions of  the  uterus.  In  some  cases  there  is  a  relaxation  or  atony  of 
the  cervix  and  lower  segment,  while  the  fundus  is  in  a  state  of  active 
contraction.  In  others  probably  the  reverse  of  this  is  the  case :  the 
atony  is  in  the  fundus  and  upper  portion  of  the  organ. 

Describe  the  symptoms. 

Pain,  shock,  and  hemorrhage  are  always  present  in  complete  inver- 
sions. The  former  is  excruciating,  often  causing  the  patient  to  cry  out 
at  the  top  of  her  voice  with  the  suffering.  The  shock  is  due  both  to  the 
pain  and  hemorrhage,  as  well  as  the  withdrawal  of  the  uterus  fi'om  the 
abdominal  cavity.     The  pulse  becomes  rapid  and  feeble,  the  face  pale 


140     HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

and  anxious,  the  extremities  cold;  there  may  be  vomiting,  sj^ncope,  con- 
vulsions, and  death,  or  the  acute  onset  of  the  sj'mptoms  is  followed  by 
remission,  during  which  they  all  improve. 

How  is  a  diagnosis  made  ? 

The  above  symptoms,  occurring  immediately  after  labor,  would  nat- 
urally lead  one  to  suspect  this  condition.  On  examining  the  abdomen 
the  hard,  rounded  fundus  is  missed,  and,  rarely,  the  depression  may  be 
felt  even  through  the  abdominal  wall. 

A  vaginal  examination  reveals  the  presence  of  a  rounded  tumor,  to 
which  the  placenta  is  possibly  attached.  If  only  partial  inversion  exists, 
the  tumor  will  be  ab.sent. 

The  condition  is  likely  to  be  confounded  with  but  one  other — a  uterine 
polypus — and  here  only  when  it  occurs  some  days  after  delivery  and 
comes  on  insidiously.  The  introduction  of  the  sound  will  soon  clear  up 
the  case.  If  a  polypus  be  present,  it  will  pass  by  it  and  up  to  the  fundus 
of  the  uterus,  but  in  a  case  of  inversion  it  is  arrested  low  down. 

What  can  be  said  of  the  prognosis  ? 

It  is  always  very  grave.  The  primary  dangers  are  both  from  shock 
and  hemorrhage,  while  subsequently  sepsis  may  occur  from  a  sloughing 
of  the  uterus  in  consequence  of  constriction  of  its  neck.  This  is  more 
likely  to  follow  if  the  condition  is  not  relieved  at  the  time  of  its  occur- 
rence. 

State  the  treatment. 

In  every  case  the  immediate  restoration  of  the  organ  to  its  normal 
condition  is  indicated ;  and  this  is  usually  attended  with  little  difficulty 
if  no  delay  occurs  in  making  the  attempt.  Every  minute  passed  ren- 
ders reposition  more  difficult. 

An  anaesthetic  should  be  administered  in  every  case  unless  the  patient's 
condition  is  such  as  to  render  it  dangerous.  If  there  be  but  a  partial 
inversion  and  only  to  a  slight  extent,  direct  pressure  with  the  fingers  of 
one  hand  against  the  inverted  jwrtion,  and  counter-pressure  with  the 
other  hand  over  the  abdominal  wall,  are  generally  productive  of  good 
results. 

If  the  inversion  be  complete,  one  of  three  courses  of  ])rocedure  may 
be  adopted:  (1)  direct  uinvard  pressure  of  the  uterus  grasped  in  the 
hand  and  in  the  axis  of  the  jiarturient  canal ;  (2)  pressure  directly  upon 
the  fundus  with  the  fingers  made  in  the  shape  of  a  cone  or  with  the 
fist;  (3)  Noeggerath's  method,  which  consists  in  ])lacing  the  index  finger 
on  one  side  of  the  uterus  near  the  entrance  of  the  Fallopian  tube,  and 
the  thumb  on  the  other.  First  one  side  is  indented  and  then  the  other, 
and  when  this  has  been  accomplished  direct  jiressure  is  made  on  the  centre 
of  the  inverted  mass  until  reduction  is  complete.  In  all  these  methods 
counter-pressure  is  made  with  the  other  hand  through  the  abdominal 
wall. 


RUPTURE  OF  THE  UTERUS.  141 

After  reduction  the  hand  should  not  be  removed  from  the  uterine 
cavity  until  firm  contraction  is  obtained  and  the  placenta  is  dissected 
from  its  attachment.  The  latter  must  not  be  removed  before  the  inver- 
sion is  relieved,  as  severe  hemorrhage  would  likely  result.  An  intra- 
uterine douche  must  always  follow. 

If  the  condition  receives  no  treatment  until  daj^s  or  weeks  after  its 
occurrence,  taxis  may  still  be  tried,  but  is  not  as  likely  to  meet  with 
success. 

Failing  in  all  attempts  at  reposition,  extirpation  of  the  organ  must  be 
done  as  a  last  resort,  though  cases  are  recorded  where  spontaneous  reduc- 
tion has  occurred. 

RUPTURE   OP   THE   UTERUS. 
What  extent  of  uterine  rupture  is  seen  ? 

There  may  be  rupture  of  the  neck  alone,  of  the  body  alone,  or  of 
both  at  the  same  time.  The  laceration  may  extend  in  a  longitudinal, 
transverse,  or  oblique  direction,  and  it  may  be  complete  or  incomplete. 
Incomplete  rupture  extends  only  through  the  muscular  wall,  while  com- 
plete involves  the  entire  thickness,  passing  through  the  peritoneal  cov- 
ering. 

The  usual  seat  is  on  the  posterior  surface,  and  more  frequently  on  the 
left  side  of  the  median  line. 

What  can  you  say  of  the  frequency  and  causes  of  uterine  rup- 
ture? 

Statistics  vary  greatly  in  regard  to  this  most  terrible  accident  of  partu- 
rition. It  fortunately  is  extremely  rare,  occurring  probably  not  oftener 
than  in  1  in  4000  cases.     It  io  OMly*«<ws'p^ffTWTHTtp?ffte. 

The  causes  may  be  divided  into  predisposing  and  immediate.  The 
predisposing  causes  are  multiparity,  abnormal  presentations,  deformed 
pelvis,  disproportion  between  the  foetus  and  the  pelvis,  prolonged  labor, 
and  thinning  of  the  lower  zone  of  the  uterus. 

There  may  be  in  multiparae  an  alteration  in  the  muscular  fibres  of  the 
uterus.  This  consists  in  a  degeneration  or  softening,  which  causes  a 
weak  power  of  contraction,  and  thus  a  prolonged  labor ;  or  the  rupture 
may  occur  from  the  softness  of  the  muscular  fibres,  even  though  the 
labor  be  not  prolonged. 

Abnormal  presentation,  especially  trunk  or  shoulder,  often  causes  rup- 
ture. 

Lack  of  proportion  between  the  child  and  pelvis  is  seen  in  deformed 
pelves  and  hj^drocephalic  children.  As  a  matter  of  fact,  rupture  occurs 
more  frequently  with  slight  deformities.  This  is  explained  by  the  sup- 
position that  with  slight  deformity  the  lower  segment  of  the  uterus  is 
crowded  down  into  the  pelvis  and  pressed  against  the  brim,  causing 
injury. 

Prolonged  labors  after  a  time  cause  a  thinning  of  the  lower  uterine 


]  42     HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

segment.  At  the  same  time  there  is  a  retraction  of  the  muscles  on  the 
upper  zone,  and  a  resukina-  thickening :  a  strong  contraction  occurs  and 
rupture  resuks.  This  condition  is  b}^  fi\r  the  most  fre(iuent  predisposing 
cause. 

The  immediate  causes  of  rupture  are — (1 )  mechanical  injury,  either 
from  manipulation,  blows,  falls,  etc.,  or  pressure  of  the  uterus  between 
some  part  of  the  child  and  the  pelvic  wall,  causing  a  congestion,  inflam- 
mation, or  sloughing  of  the  tissue ;   (2)  strong  uterine  contractions. 

Describe  the  symptoms. 

Premonitory  ^iimptoms<  have  been  described,  but  the^'  are  too  vague  to 
even  mention.  The  accident  usually  takes  place  very  suddenly  and  during 
a  strong  expulsive  pain,  and  is  accompanied  by  a  severe  agonizing  pain 
associated  with  a  tearing  sensation.  It  is  said  that  a  snapping  sound, 
audible  to  the  patient  and  bj^standers,  sometimes  occurs  at  the  time  of 
the  rupture.  Uterine  contractions  immediately  cease  :  the  pulse  becomes 
irregular,  rapid,  and  thready :  the  face  is  pale  ;  the  body  is  covered  with 
a  cold  perspiration ;  the  respirations  are  rapid,  shallow,  and  sighing ; 
nausea  and  vomiting  take  place,  and  may  be  follo\yed  by  blindness,  ring- 
ing in  the  ears,  and  possibly  convulsions.  There  is  always  more  or  less 
hemorrhage,  though  this  may  not  be  visible,  as  the  blood  escapes  into 
the  abdominal  cavity. 

How  is  the  diagnosis  made  ? 

On  making  an  abdominal  examination  the  foetal  parts  are  felt  just 
under  the  hand,  and  a  tumor  entirely  separate  from  the  child  is  appre- 
ciated. This  is  the  uterus.  Vaginal  examination  fails  to  find  any  pre- 
senting part.  It  has  receded  from  the  reach.  The  rent  in  the  uterus 
may  occasionally  be  felt,  and  it  sometimes  happens  that  a  loop  of  intes- 
tine has  slipi>ed  through  it  and  is  visible  at  the  vulva. 

What  is  the  prognosis? 

Very  grave.  Death  may  occur  immediately  from  shock  or  hemor- 
rhage. The  child  ahnost  invariably  dies.  For  the  mother  the  prognosis 
depends  considerably  upon  the  extent  of  the  laceration,  and  \yhether  or 
not  the  foetus  has  escaped  into  the  abdominal  cavity.  Statistics  show 
about  10  or  15  per  cent,  of  recoveries. 

State  the  methods  of  treatment. 

J^(>j)hi/l(icfic. — This  consists  in  terminating  a  labor  which  is  becoming 
so  prolonged  as  to  cause  a  thinning  of  the  lower  uterine  segment,  and  in 
immediate  delivery,  either  by  craniotomy  or  embryotomy,  in  case  a  very 
thin  lower  segment  is  found.  All  rough  or  improper  manipulations 
during  labor  are  to  be  avoided. 

In  case  rupture  has  occurred,  one  of  two  courses  is  to  be  pursued, 
depending  upon  the  conditions  present  (any  form  of  expectant  treat- 
ment is  never  justifiable): 


ACCIDENTS   TO    ^lOTHER,    AND   SUDDEN    DEATH.  143 

If  the  rent  be  small  and  the  child  has  not  escaped  into  the  abdominal 
cavit}^  deliver  as  rapidly  as  possible.  Whichever  method  offers  the 
g-reatest  chance  for  a  speedy  delivery  should  be  employed,  whether  it  be 
the  use  of  forceps,  version,  craniotomy,  or  embryotomy.  After  the 
birth  of  the  child,  carefully  and  gently  remove  the  placenta  and  wash 
out  the  uterine  cavity  with  warm  distilled  water. 

If  the  foetus  has  partially  or  wholly  escaped  into  the  abdominal  cavity, 
laparotomy  is  the  only  treatment.  Remove  the  child  and  blood-clots, 
wash  out  the  abdominal  cavity,  and  sew  up  the  uterus. 

Some  go  so  far  as  to  recommend  laparotomy  in  every  case  of  ruptured 
uterus,  though  the  majority  are  hardly  of  the  opinion  that  this  course  is 
justifiable. 

The  after-treatment  consists  in  stimulants,  a  light  nutritious  diet, 
opium  if  necessary,  and  the  introduction  of  a  long  glass  drainage-tube 
into  the  uterus  and  just  through  the  rupture  if  laparotomy  has  not  been 
done.  At  the  end  of  a  few  days,  when  adhesions  have  formed,  the 
uterine  cavity,  if  necessary,  may  be  occasionally  irrigated  with  warm 
sterilized  water. 

ACCIDENTS  TO  MOTHER,  AND  SUDDEN  DEATH. 

Name  the  injuries  which  may  occur  along  the  parturient  canal 
during  labor. 

(1)  Lacerations  of  the  Os  Eccternvm. — These  almost  invariably  occur 
with  every  labor,  and  are  of  no  consequence. 

(2)  Lacerations  of  the  Cervix. — These  may  be  slight  and  confined  to 
one  side  only  (unilateral) ;  they  may  take  place  on  both  sides  (bilateral) ; 
or  there  may  be  lacerations  throughout  the  entire  circumference  of  the 
cervix  ^stellate).  Cases  have  occurred  where  a  narrow  ring  of  the  cervix 
has  been  torn  away. 

It  rarely  happens  that  any  immediate  treatment  is  necessary  unless  the 
hemorrhage  be  profuse,  in  which  case  the  application  of  some  styptic 
(subsulphate  of  iron)  will  immediately  check  the  flow  of  blood,  and  the 
cervix. may  be  repaired  after  the  woman  has  recovered  from  the  effects 
of  parturition. 

(3)  Lacerations  of  the  Vagina. — These  never  become  grave  unless 
occurring  in  the  upper  portion  of  the  canal.  A  few  cases  are  recorded 
where  the  rent  has  taken  place  in  the  vault  and  fornix,  causing  symptoms 
similar  to  those  occurring  with  rupture  of  the  uterus.  However,  they 
are  extremely  rare.  Injury  farther  down  should  be  repaired  when  labor 
is  completed. 

(4)  Tears  of  the  Vulva  will,  as  a  rule,  be  of  little  moment  unless  such 
injury  occurs  as  to  cause  thrombosis.  This  condition  has  already  been 
described. 

(5)  Injuries  to  the  Petnneum. 

(6)  Injury  to  the  Pelvic  Jrn'nts. — This  rare  occurrence  may  be  the  result 
of  violent  deliveries,  especially  when  some  disproportion  exists  between  the 


144    HEMORRHAGES,  INJURIES,  AND  ACCIDENTS  OF  LABOR. 

head  and  pelvis,  or  it  may  be  the  result  of  pathological  changes  in  the 
articulations.  It  consists  in  a  slight  tearing  apart  or  loosening  of  one  of 
the  joints,  most  frequently  the  pubic. 

Some  pain  upon  moving  about  will  be  the  only  symptom. 

The  treatment  consists  in  the  application  of  a  bandage  which  will 
render  the  joint  immovable.     Complete  rest  must  be  enjoined. 

State  the  causes  of  sudden   death  during  or  immediately  after 
delivery. 

(1)  Exhaustion  and  suffering  (very  rare) ;  (2)  air  in  the  uterine  sin- 
uses; (3)  mental  emotion;  (4)  affections  of  the  respiratory  organs 
(acute  pulmonary  congestion  and  oedema);  (5)  thrombosis  and  em- 
bolism; (6)  rupture  of  the  aorta  from  increased  tension,  owing  to  the 
uterine  contraction;  (7)  diseases  of  the  heart.  A  few  other  causes  of 
sudden  death  at  this  time  have  been  described,  but  they  are  of  extremely 
rare  occurrence.  Many  causes  have  already  been  described — inversion 
and  rupture  of  the  uterus,  hemorrhage,  etc. 

Is  death  from  emotional  causes  often  seen? 

It  is  not,  though  a  few  cases  are  recorded  where  extreme  joy  or  sor- 
row has  been  the  cause  of  sudden  death  after  labor,  and  in  which  an 
autopsy  revealed  no  pathological  conditions. 

State   the   causes  and  symptoms  of  the   access   of  air  in  the 
uterine  sinuses  ? 

Air  enters  the  uterine  sinuses  generally  from  improper  management 
of  the  patient  immediately  after  labor,  though  it  may  be  a  purely  un- 
avoidable accident.  Carelessness  in  allowing  air  to  pass  through  the 
tube  in  giving  an  intra-uterine  douche,  and  in  carrying  the  hand  into  the 
uterus  when  this  is  necessary,  is  the  most  frequent  way. 

The  symptoms  are  extreme  pallor,  dyspnoea,  perhaps  vomiting,  col- 
lapse, and  death. 

What  disease  of  the  heart  most  frequently  causes  death  at  this 
time? 

Fatty  degeneration  alone  or  associated  with  dilatation.  ltui)ture  of 
the  organ  may  occur  from  a  myocarditis,  as  well  as  the  above,  and  is 
sometimes  due  to  violent  straining  efforts. 

What  are  the  usual  seats  of  puerperal  thrombosis  ?    State  the 
causes  ? 

The  j)ulnionary  arteries  and  the  right  side  of  the  heart  are  the  usual 
seats.  The  primary  causes  of  thrombosis  are  some  mechanical  obstruc- 
tion, around  which  coagula  form  ;  an  imi)eded  or  arrested  circulation ; 
and  i)athological  changes  in  the  blood  which  render  it  more  easy  of 
coagulation. 

The  fact  that  at  least  two  of  these  conditions  exist  in  the  puerperal 
state  renders  the  accident  more  frequent  at  this  time  than  under  ordi- 


INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR.  145 

nary  circumstances.  The  blood  of  the  post-partiini  woman  is  very  coag- 
ulable,  owing  to  the  increased  amount  of  fibrin  already  spoken  of;  then 
the  exhaustion,  and  perhaps  hemorrhage,  immediately  succeeding  labor 
predispose  to  thrombosis.  The  great  majority  of  cases  occur  after  a  post- 
partum hemorrhage. 

Describe  the  symptoms. 

Either  a  thrombosis  of  the  pulmonary  vessels  or  of  the  right  heart 
causes  practically  the  same  symptoms,  though  in  the  latter  death  is 
likely  to  occur  more  quickly.  No  premonitory  signs  occur,  and  the 
patient  seems  to  be  doing  well  when  she  is  suddenly  attacked  with  the 
most  violent  dyspnoea.  The  face  is  either  cyanotic  or  pale,  and  the 
struggles  to  get  air  are  frightful.  The  pulse  is  rapid  and  feeble  or  en- 
tirely absent :  there  is  a  sense  or  feehng  of  impending  death,  which  may 
occur  almost  immediately  in  a  convulsion,  or  the  symptoms  may  improve 
somewhat. 

The  2^yognosis  is  very  grave,  though  cases  have  recovered  and  the  clot 
become  absorbed. 

Is  there  any  treatment  for  this  condition? 

Death  generally  results  too  soon  to  allow  of  any  plan  of  treatment 
being  carried  out.  If  this  does  not  occur  immediately,  we  should  keep 
the  woman  at  absolute  rest  and  administer  stimulants. 

What  can  you  say  of  embolism  ? 

It  is  an  obstruction  to  the  circulation,  the  result  of  either  a  detachment 
of  a  portion  of  a  thrombus  or  of  a  detached  vegetation  from  one  of  the 
cardiac  valves. 

The  i^ymptoms,  if  it  occur  in  the  pulmonary  artery  and  right  heart,  are 
exactly  the  same  as  those  described  above,  though  their  onset  may  be 
more  gradual. 


CHAPTER  VII. 

OBSTETRIC    OPERATIONS. 

INDUCTION  OP  ABORTION  AND  PREMATURE  LABOR. 

State  the  most  frequent   causes  demanding  the   induction  of 
abortion. 

(1 )  Extreme  contractions  of  the  pelvis  (below  2  inches) ;  (2)  encroach- 
ment of  large  tumors  on  the  pelvic  canal;  (3)  cicatrices  of  cervix  or 
vagina  not  admitting  of  dilatation  ;  (4)  some  cases  of  cancer  of  the  cer- 
vix; (5)  irreducible  retroversion  or  procidentia  of  the  uterus;  (6)  fixing 
of  uterus  by  adhesion  ;  (7)  some  uterine  tumors ;  (8)  uncontrollable  vom- 

lO—Obs. 


146  OBSTETRIC    OPERATIONS. 

iting  with  profrressivc  emaciation  and  exhaustion;  (9)  some  cases  of 
albuminuria  witli  nephritis;  (10)  some  cases  of  chorea  and  insanity';  (11) 
placenta  praevia:  (12)  heart  diseases  with  extreme  dyspnoea;  (13)  C3^stic 
degeneration  of  the  chorion  (McLane). 

When  should  premature  labor  be  induced  ? 

Premature  labor  is  anj^  labor  occurring  after  viability  of  the  child,  but 
before  full  term.  Any  condition,  either  of  the  mother  or  child,  which 
would  render  dangerous  or  fatal  the  continuance  of  pregnancy  calls  for 
the  induction  of  premature  labor. 

Conditions  of  the  foetus  demanding  it  are  (1)  an  habitually  large  size 
of  the  head  or  premature  ossification  of  the  bones  of  the  skull,  as  shown 
by  former  labors.  In  this  case  the  woman  should  be  allowed  to  go  nearly 
to  term.  (2)  Repeated  deaths  of  the  foetus  in  utero  during  the  latter  part 
of  gestation.  This  is  caused  by  some  form  of  degeneration  of  the  pla- 
centa.    (3)  Death  of  the  foetus  in  utero. 

Conditions  of  the  mother  which  call  for  this  operation  may  be  anj^^  of 
those  mentioned  under  the  indications  for  abortion :  pelvic  deformity, 
forbidding  dehvery  at  term  ;  uncontrollable  vomiting ;  advancing  albu- 
minuria, or  jaundice  ;  eclampsia  ;  placenta  pr?evia ;  hj^dramnion,  when 
dyspnoea  is  urgent ;  extensive  ascites ;  grave  diseases  of  lungs  or  heart ; 
tumors,  etc. 

It  should  always  be  borne  in  mind  that  neither  an  abortion  nor  a 
premature  labor  should  ever  be  induced  without  a  consultation,  unless 
the  case  be  urgent  and  no  time  allowed  for  calling  a  consultant. 

When  is  the  period  of  viability  ? 

There  is  a  fair  chance  for  a  living  child  after  210  days,  though  between 
this  time  and  230  to  240  days  there  must  be  a  strong  feeling  of  uncer- 
tainty. After  250  days  we  may  feel  sure  of  a  living  foetus.  Always 
count  from  the  last  day  of  the  last  menstruation. 

What  should  be  the  prognosis  when  labor  is  induced  ? 

Always  guarded,  though  depending  almost  entirely  upon  the  cause 
demanding  the  operation. 

The  uterus  is  not  ready  to  expel  its  contents  ;  manipulations  are  neces- 
sary ;  hence  greater  risks  of  hemorrhage  and  sepsis ;  not  only  these,  but 
the  condition  of  the  mother  calling  for  the  operation  may  be  such  as  to 
add  other  dangers. 

For  the  child  it  is  never  very  good  unless  the  gestation  be  near  term. 

What  is  the  best  method  of  inducing  abortion  ? 

Puncturing  the  membranes  with  a  Sims  sound.  Contractions,  as  a 
rule,  will  soon  come  on,  and  the  foetus,  membranes,  and  j^lacenta  all  be 
expressed.  If  any  of  the  secundines  be  retained,  the  cervix  must  be 
more  fully  dilated,  and  with  a  dull  curette  the  entire  cavity  cleaned  out. 
The  fin^^ers  are  preferable  to  the  curette  if  the  pregnancy  has  advanced 
to  the  fourth  month.     Bear  in  mind  the  fact  that  absolute  cleanliness 


INDUCTION    OF    ABORTION   AND    PREMATURE    LABOR.     147 

and  antisepsis  must  be  observed  in  the  performance  of  tlie  ()i)eration. 
Tliorough  cleansinu'  of  the  i)arts  about  tlie  vulva,  a  vaginal  douche,  ster- 
ilization of  the  instruments  and  the  hands  of  the  operator  and  his  assist- 
ants, must  precede  any  manipulation. 
The  after-treatment  of  abortion  is  just  as  it  is  for  labor  at  full  term. 

Mention  the  different   methods  for  the   induction  of  labor,  and 
state  which  are  the  best. 

(1)  Rupture  of  the  membranes;  {2)  intra-uterine  douches;  (3)  intro- 
duction within  the  uterus  of  a  gum-elastic  catheter  or  bougie  ;  (4)  dilata- 
tion of  the  cervix  ;  (5)  vaginal  douches  ;  (6)  tamponing  vagina  ;  (7)  elec- 
tricity (either  the  galvanic  or  the  faradic  current)  ;  (8)  use  of  medicines, 
cither  oxytocics  or  purgatives.  Several  others  have  been  used,  but  are 
entirely  discarded.  Among  those  mentioned,  but  two  should  be  used, 
taking  as  adjuncts  some  of  the  others.  These  are  puncture  of  the  mem- 
branes and  the  introduction  of  a  flexible  bougie.  Combined  with  either 
of  these,  vaginal  douches,  dilatation  of  the  cervix,  and  tampons  may  all 
be  of  great  utility  in  some  cases ;  but  the  use  of  any  of  the  latter  three 
alone  is  to  be  discouraged. 

Describe   the  steps   to  be  taken  in  inducing  labor  in  a  case  of 
albuminuria  or  a  contracted  pelvis. 

The  methods  now  to  be  described  are  to  be  pursued  in  all  cases  where 
time  is  allowed.  In  some  cases  of  placenta  pnievia  or  eclampsia,  as  has 
been  mentioned,  the  immediate  rupture  of  the  membranes  is  indicated  : 

(1)  Preparation  of  the  patient  and  the  selection  of  the  time;  (2) 
preparation  of  the  implements,  operator,  and  assistants  ;  (3)  introduction 
of  the  bougie ;  (4)  removal  of  the  bougie.  The  evening  is,  as  a  rule, 
])referable  for  introducing  the  bougie :  as  the  pains  generally  will  not 
l)cgin  before  morning,  the  labor  may  be  terminated  by  the  following- 
night,  and  thus  neither  patient  nor  physician  loses  any  sleep. 

Tlie  preparation  of  the  woman  consists  in  giving  her  a  warm  vaginal 
douche  of  bichloride  of  mercury,  I  :  5000,  or  of  carbolic  acid,  1  :  60  or  (SO, 
emptying  the  bowel  by  an  enema,  and  noticing  that  the  bladder  is  also 
empty.  She  should  then  be  placed  so  that  the  buttocks  come  to  the 
edge  of  the  bed.  A  gum-elastic  bougie  (No.  12  American  is  a  desirable 
size),  perfectly  new,  should  be  placed  either  in  a  solution  of  carbolic  acid, 
1  :  20,  or  of  bichloride  of  mercury,  1  :  1000  (cold),  and  allowed  to  be 
thoroughly  immersed  for  at  least  half  an  hour  before  its  introduction. 
A  needle  carrying  a  long  piece  of  silk  suture  should  be  passed  through 
the  end  of  the  bougie,  that  it  may  be  easily  withdrawn  when  necessary. 
Cotton  tampons,  sterilized,  are  to  be  at  hand.  The  hands  and  arms  of 
the  physician  and  his  assistants  must  be  scrubbed  with  soap  and  water, 
washed  with  alcohol  or  ether,  and  submerged  for  a  miiuite  or  two  in  the 
bichloride  solution. 

Everything  now  being  in  readiness,  a  little  chloroform  is  given.  The 
first  two  fingers  of  the  right  hand  are  introduced  to  the  cervix,  and, 


148  OBSTETRIC   OPERATIONS. 

using  them  as  a  guide,  the  bougie  is  passed  through  the  os  into  the 
uterus.  Very  gentle  pressure  must  be  exerted,  to  prevent  if  possible 
rupturing  of  the  membranes.  If  any  obstruction  be  encountered,  the 
bougie  should  be  immediately  withdrawn,  as  it  has  probably  come  in 
contact  with  the  placenta.  Now  introduce  it  on  the  opposite  side.  At 
least  eight  or  nine  inches  are  passed  into  the  uterus,  one  or  two  tampons 
introduced  to  prevent  its  slipping  out,  and  an  aseptic  vulvar  pad  applied. 

It  sometimes  happens  that  the  os  is  too  tightly  closed  to  allow  of  the 
introduction  of  the  bougie.  If  such  be  the  case,  some  dilatation  must 
first  be  accomplished  by  the  employment  of  a  pair  of  hard  dilators  or 
the  finger.  A  bougie  is  preferable  to  the  gum-elastic  catheter,  as  it 
contains  no  opening  or  eye  through  which  air  or  sepsis  might  get  up  into 
the  uterus. 

At  the  end  of  a  few  hours  the  pains  will  usually  begin,  and  when  the 
patient  is  seen  in  the  morning  labor  may  be  well  under  way.  Now  re- 
move the  tampon.  From  now  on  the  case  is  to  be  managed  as  one  of 
normal  labor,  only  that  the  bougie  must  be  withdrawn  when  the  os  is 
about  one-half  or  two-thirds  dilated. 

Is  it  ever  necessary  to  resort  to  other  methods  or  means? 

It  is.  Though  uterine  contractions  may  begin  within  a  couple  of 
hours,  cases  occasionally  go  for  days  without  labor  beginning.  The  in- 
strument should  not  be  allowed  to  remain  longer  than  twenty-four  hours 
if  the  desired  results  do  not  follow.  Remove  it  and  introduce  another 
in  some  other  part  of  the  uterus,  or  first  dilate  the  cervix  with  Barnes' 
bags.     This  is  frequently  a  very  valuable  accessory. 

In  case  rajiid  delivery  should  become  imperative  after  contractions 
have  begun,  the  dilators  may  also  be  used  until  the  cervix  will  admit  of 
the  application  of  the  forceps. 

What  care  should  a  premature  infant  receive? 

It  must  be  carefully  wrapped  in  plain  cotton  and  kept  in  a  warm  place. 
Do  not  allow  a  bath  to  be  given  for  two  or  three  weeks  at  least.  It 
should  bc/^^(/,  and  not  allowed  to  nurse,  as  the  effort  is  too  exhausting. 
If  possible,  a  wet-nurse  ought  to  be  obtained,  and,  beginning  a  few  hours 
after  birth,  she  should  squeeze  from  her  breasts  a  couple  of  teaspoonfuls 
of  milk,  which  may  be  given  to  the  child  with  a  si)oon  or  medicine- 
dropper  every  couple  of  hours  during  the  night  as  well  as  day. 

VERSION. 
What  is  version? 

Version  or  tui-ning  is  the  operation  by  which  the  position  of  the  foetus 
in  utero  is  altered,  so  that  some  one  portion  of  the  body  is  substituted 
for  the  part  originally  presenting. 

There  are  two  general  varieties :  cephalic^  or  the  substitution  of  the 
head  for  some  other  part ;  and  podalic^  or  the  substitution  of  the  feet 
for  another  part. 


VERSION.  149 

How  may  versions  be  done  ? 

Either  cephalic  or  podaHc  may  be  clone  by  o;f6T?ia?  manipulations  alone, 
by  internaJ  manipulations  alone,  or  by  external  and  internal  combined. 
''Bimanual  "  means  the  using  of  both  hands.  "Bipolar"  means  tliat 
during  the  operation  both  poles  or  extremities  of  the  foetus  are  acted 
upon  by  the  two  hands. 

State  the  indications  requiring   cephalic  version,  and  what  con- 
ditions are  favorable  to  its  successful  performance. 

Malpositions  of  the  foetus  are  the  general  indications  for  this  variety 
of  version,  and  more  especially  transvei^se  or  shoulder  presentations.  It 
may  also  be  indicated  in  slight  pelvic  contractions,  where  during  the  last 
month  of  gestation  the  head  lies  out  of  the  pelvis  in  one  iliac  fossa. 
Some  advise  its  performance  in  breech  presentations.  It  is  contraindi- 
cated  where,  from  one  cause  or  another,  rapid  deliver}^  is  desired. 

The  conditions  which  make  the  operation  most  favorable  are — an  un- 
ruptured amniotic  sac :  a  movaVjle  foetus :  an  opportunity  of  operating 
before  labor  has  begun,  or  at  least  before  the  pains  have  become  strong 
and  the  os  dilated  ;  a  multipara. 

Describe  the  method  of  doing  an  external  cephalic  version. 

The  patient  is  placed  upon  her  back,  with  the  legs  flexed  at  the  knees 
and  the  thighs  on  the  pelvis.  One  hand  is  placed  over  the  head,  the 
other  over  the  breech  of  the  foetus.  Gentle  downward  pressure  is  made 
with  the  one,  pushing  the  head  into  the  pelvis,  and  at  the  same  time  up- 
ward pressure  is  made  on  the  pelvic  extremity.  As  soon  as  the  position 
is  rectified  place  a  compress  of  some  kind  (a  folded  towel  will  answer) 
over  the  lower  part  of  the  abdomen,  where  the  breech  formerly  rested, 
and  another  at  the  opposite  side  of  the  breech ;  then  apply  an  abdom- 
inal binder. 

Describe  the  combined  method. 

The  external  method  having  been  tried  without  result,  we  should  then 
resort  to  the  combined  method.  3Iany  have  been  described,  but  none 
have  met  with  so  much  success  as  the  Braxton -Hicks  method. 

Care  is  taken  to  see  that  both  the  bladder  and  rectum  are  empty  be- 
fore proceeding.  Ether  should  be  administered  to  the  surgical  degree. 
A  warm  antiseptic  vaginal  douche  is  given  and  the  hands  rendered  thor- 
oughly sterile.  Then  introduce  one  hand  into  the  vagina  and  two  fingers 
through  the  cervix.  The  shoulder  will  be  felt  lying  over  the  os,  and  this 
is  pushed  upward  in  the  direction  of  the  feet.  At  the  same  time,  with 
the  free  hand  over  the  abdomen  the  breech  is  pushed  toward  the  median 
line  or  the  head  crowded  down  into  the  pelvis.  We  now  have  the  head 
between  the  two  hands,  and  if  there  is  any  teixlency  to  a  face  presenta- 
tion it  may  easily  be  rectified. 

If  the  membranes  be  intact  at  the  completion  of  the  operation,  they 


150  OBSTETRIC   OPERATIONS. 

should  be  ruptured,  that  the  tendency  to  a  return  to  the  abnormal  posi- 
tion be  obviated. 

Is  internal  cephalic  version  ever  indicated? 

Only  in  cases  of  face  presentation  TPith  the  chin  posterior.  The  method 
of  rectifying  this  condition  has  already  been  spoken  of  under  Face  Pres- 
entations. 

What  are  the  indications  for  podalic  version? 

Any  of  those  mentioned  under  Cephalic  when  this  has  been  tried  un- 
successfully ;  placenta  prtevia  ;  some  cases  of  prolapse  of  the  funis ;  rup- 
ture of  the  uterus ;  shoulder  presentation  with  prolapsed  arm;  eclamp- 
sia,— in  fact,  any  case  in  which  rapid  delivery  is  necessary,  and  whei-e 
this  can  be  accomplished  most  speedily  by  securing  a  foot  and  extracting. 

What  are  the  conditions  essential  to  its  successful  performance  ? 
and  when  is  it  contraindicated  ? 

( 1 )  An  OS  nearly  or  com])letely  dilated,  or  at  least  one  capable  of  dila- 
tation (soft).  (2)  Unruptured  membranes  or  a  uterus  from  which  the 
lif}uor  amnii  has  just  escaped.  (.3)  A  presenting  part  that  is  not  wedged 
into  the  pelvis,  and  preferably  before  engagement  has  taken  place.  (4) 
A  ]>elvis  roomy  enough  to  allow  of  the  introduction  of  the  hand. 

Podalic  version  is  absolutely  contraindicated  in  cases  where  the  labor 
has  been  so  prolonged  that  the  lower  segment  of  the  uterus  is  thinned 
out.  or  where,  from  some  cause  or  other — generally  from  the  improper 
administration  of  oxytocics — the  uterus  is  spasmodically  contracted  over 
the  child.  Rupture  in  either  case  is  almost  sure  to  result.  It  is  also 
contraindicated  with  marked  pelvic  contractions  or  a  vaginal  canal  of 
diminished  size. 

What  should  be  the  position  of  the  patient?   and  what  should 
always  be  in  readiness  when  podalic  version  is  done? 

The  dorsal  decubitus  is  i)r(jbaljly  always  desirable,  the  patient  lying 
crosswise  in  the  bed,  with  buttocks  well  to  the  edge.  Just  as  in  all 
obstetric  operations,  the  bladder  and  bowel  should  be  emptied  and  a 
vaLMnal  douche  given. 

The  forceps  must  be  at  hand,  in  case  they  are  needed  for  delivery  of 
the  after-coming  head,  and.  as  the  child  is  likely  to  be  born  asph3'xiated, 
hot  and  cold  water,  ice,  warm  blankets,  alcohol,  etc.  must  be  in  readi- 
ness, that  no  delay  in  its  resuscitation  may  occur. 

An  anaesthetic — preferably  ether — should  be  administered.  The  choice 
of  the  hand  to  be  introduced  into  the  vagina  is  generally  considered  oi" 
httle  importance :  however,  as  it  may  become  necessary  to  introduce  it 
entirely  into  the  uterine  cavity,  it  is  advisable  to  follow  this  plan  :  If  the 
abdomen  ol'  the  foetus  points  to  the  left  side  of  the  mother,  the  right 
hand  of  the  operator  is  used,  and  vice  versa. 


VERSION. 


151 


Describe  the  combined  or  Braxton-Hicks  method. 

It  resolves  itself  into  three  stages:  (1)  The  introduction  of  the  hand; 
(2)  the  removal  of  the  presenting  part  and  substitution  of  the  leg;  (3) 
extraction. 

The  hand  is  gently  and  carefullj^  introduced  into  the  vagina,  pressing 
continually  upon  the  perineum,  and  not  the  soft  parts  under  the  sym- 
physis, and  the  two  fingers  passed  through  the  cervix. 

Fig.  38. 


Braxton-Hicks  Method  of  Version  :  first  step. 

If  the  case  be  a  vertex,  the  fingers  are  in  contact  with  the  crown  of 
the  head,  and  an  attempt  must  be  made  to  push  it  in  the  direction 
toward  which  the  occiput  points  (Fig.  38).     Thus  in  the  first  and  fourth 


152 


OBSTETRIC   OPERATIONS. 


positions  it  is  pushed  toward  the  left,  and  in  the  second  and  third  toward 
the  right.  With  the  other  hand  over  the  abdomen  the  breech  is  pushed 
downward  on  tlie  opposite  side.  The  shoulder  will  now  come  within 
reach,  and  it  is  pushed  along  in  a  similar  manner  (Fig.  39) ;  at  the  same 
time  the  breech  is  still  further  depressed.  The  membranes,  if  not  al- 
read}^  so,  must  now  be  ruptured,  that  a  knee  or  foot  ma}'  be  seized  and 


Fig.  39. 


Version :  second  step. 


drawn  down  into  the  vagina  (Fig.  40).  The  external  hand  should  then 
be  changed  to  the  cephalic  extremity,  and  upward  jiressure  made  upon 
this. 

If  the  shoulder  present,  and  the  arm  be  not  prolapsed,  and  if  the 
membranes  are  still  intact,  we  would  naturally  attempt  a  cephalic  ver- 
sion. Failing  in  this,  the  course  of  procedure  described  above  would  be 
pursued. 


VERSION. 

Fig.  40. 


153 


Version  :  third  step  (beginning). 

What  advantages  has  this  method  over  the  internal? 

The  hand  does  not  have  to  be  introduced  into  the  nterus.  This  is  a 
procedure  alwaj^s  accompanied  with  some  considerable  risk,  not  only 
that  there  is  greater  danger  of  carrying  in  sepsis,  but  with  the  organ  in 
active  contraction  and  its  cavity  completely  filled  we  add  the  danger  of 
possible  rupture  by  over-distension. 

Describe  the  operation  of  internal  version. 

This  is  usually  a  very  easy  operation,  provided  the  membranes  have 
but  recently  ruptured.  In  vertex  cases  the  hand  is  introduced  into  the 
vagina  with  a  slow,  boring  motion  until  the  cervix  is  reached.  If  this 
be  dilated  sufficiently  to  allow  its  passage,  push  the  hand  through,  by 
the  fice  and  up  along  the  abdomeii  of  the  child.  As  soon  as  a  uterine 
contraction  begins  cease  all  manipulations  and  allow  the  palm  of  the 
hand  to  press  firmly  against  the  bell.y  of  the  foetus,  that  the  knuckles 
may  not  injure  the  uterus.  As  we  pass  along  up,  the  elbows,  arms,  and 
hands  are  felt,  and  just  above  a  knee  is  found.     The  finger  and  thumb 


154 


OBSTETRIC   OPERATIONS. 


Fig.  41 


are  hooked  around  this  (Fig.  41)  and  traction  made,  stopping  as  soon  as 

the  uterus  contracts.  .  i  i  i 

As  we   draw  downward 

upon  the  leg  our  manoeu- 
vres ma\^  be  much  facil- 
itated by  upward  pressure 
on  the  child  s  head,  with  a 
hand  over  the  abdomen. 

If  the  membranes  are 
intact  when  the  operation 
is  begun,  they  should  be 
ruptured  as  the  hand  is 
passed  through  the  os. 

In  shoulder  presenta- 
tions the  only  difference 
lies  in  the  fact  that  the 
feet  will  not  be  found  as 
high  up. 

If  the  arm  be  prolapsed, 
a  piece  of  muslin  a  couple 
of  inches  broad  should  be 
fastened  about  the  wrist, 
and  made  long  enough  to 
permit  the  end  to  remain 
outside  of  the  vulva  after 
the  child  is  turned.  As 
traction  is  made  upon  this 
during  the  delivery  of  the 
body  and  head,  the  arm  is 
swept  over  the  face,  and 
the  unfortunate  complica- 
tion of  an  extension  of  this 
member  thus  prevented. 
Tlie  operation  of  turning 
in  these  cases  does  not 
differ  in  the  slightest  from 
the  internal  versions.  The  arm  after  being  snared  is  not  touched,  but 
allowed  to  slip  up  into  the  uterus  as  the  breech  descends  and  the  head 
rises. 

Which  foot  should  be  brought  down  in  doing  an  internal  ver- 
sion ?  and  would  you  ever  bring  both  ? 

In  vertex  ca.ses  it  is  i)erfectly  immaterial  which  knee  is  seized  ;  simply 
secure  the  one  most  easy  of  access.  In  transverse  presentations  where 
the  back  of  the  child  lies  anteriorly,  many  recommend  drawing  down 
the  upper  foot,  while  some  tliink  it  better  to  take  the  lower. 

It  is  never  advisable  to  draw  down  both  limbs,  unless  the  os  be  com- 


iDternal  Version  :  grasping  the  foot. 


THE   FORCEPS.  155 

pletely  dilated,  the  pelvis  roum3^  and  the  parturient  canal  large ;  and 
even  under  these  circumstances  it  is  not  necessary. 

How  would  you  proceed  in  regard  to  the  extraction  of  the  foetus  ? 

From  the  time  the  leg  has  been  brought  into  the  vagina  the  case  is  to 
be  treated  exactly  as  a  breech  presentation.  If  the  foetal  heart  is  good 
and  the  condition  of  the  mother  does  not  demand  immediate  delivery, 
allow  this  to  be  accomplished  by  the  natural  forces.  We  always  have 
present  a  condition  of  affairs  where  delivery  can  be  completed  within  a 
very  short  space  of  time  if  it  becomes  necessary  ;  and  as  there  is  more 
danger  of  extended  head  and  arms  if  traction  is  made,  we  should  not 
resort  to  it  unless  the  conditions  present  demand  such  interference. 

What  are  the  dangers  of  version  ?    Mention  the  difficulties  often 
encountered  during  its  performance. 

To  the  mother,  rupture  of  the  uterus,  injury  to  the  organ  so  that  in- 
flammatory conditions  result,  and  sepsis  are  the  grave  dangers.  To  the 
child,  injury,  or  even  death,  may  be  caused  by  our  manipulations.  The 
difficulty  frequently  encountered  is  a  failure  of  the  head  and  shoulders 
to  ascend  as  the  foot  is  drawn  down.  Upward  pressure  over  the  abdo- 
men may  be  sufficient  to  cause  these  parts  to  recede.  If  not,  a  noose 
may  be  slipped  over  the  ankle  and  traction  made  upon  this,  while  with 
two  fingers  in  the  vagina  upward  pressure  is  made  on  the  shoulder. 

Cases  now  and  again  occur  where  all  attempts  at  the  hands  of  the 
most  competent  operators  fail,  and  embryotomy  or  craniotomy  becomes 
necessary. 

THE  FORCEPS. 

What  are  the  requisites  of  a  good  pair  of  obstetrical  forceps  ? 

(1)  They  should  be  easy  of  application  and  removal.  (2)  They  should 
retain  their  hold  and  not  "slip.  This  will  be  accomplished  if  they  possess 
the  proper  cephalic  and  pelvic  curves.  (3)  They  should  be  strong  and 
of  proper  length.  (4)  They  must  have  as  little  divergence  as  possible  at 
the  shank.     (5)  The  shoulder  should  be  broad  and  strong. 

The  ordinary  forceps  are  about  14  inches  long,  and  composed  of  three 
parts — blades,  shank,  and  handles.  The  former  may  be  perfectly  solid 
or  fenestrated,  and  are  distinguished  as  right  and  left  or  male  and  female. 

There  are  the  so-called  axis-traction  forceps  of  Tarnier,  as  well  as 
many  modifications,  which  differ  from  the  original  instrument  princi- 
pally in  possessing  a  curved  handle,  which  is  fastened  near  the  base  of 
the  blades,  and  by  which  ti-action  can  be  made  directly  in  the  axis  of  the 
pelvic  canal. 

What  powers  may  be  exerted  by  the  forceps? 

(1)  Traction.— The  amount  used  must  depend  entirely  upon  the  con- 
ditions demanding  their  use. . 


156  OBSTETRIC   OPERATIONS. 

(2)  Compression. — A  little  is  always  necessary,  but  it  should  never  be 
kept  up  continuously.  The  forceps  are  not  maintained  in  apposition  with 
the  foetal  head  by  compression  on  tlie  handles,  but  Ijy  pressure  exerted 
upon  the  blades  by  the  soft  parts  and  pelvis  of  the  mother. 

(3)  Leverage. — This,  though  perhaps  slight,  is  exerted,  or  should  be, 
in  every  forceps  delivery. 

State  the  difference  between  "high"  and  "low"  forceps  opera- 
tions. 

When  the  instrument  is  applied  with  the  head  at  or  above  the  brim 
of  the  pelvis,  it  constitutes  the  "  high  operation."  When  low  down  or 
at  the  pelvic  outlet,  it  constitutes  the  "  low  operation." 

Mention  the  conditions  necessary  for  their  use. 

(1)  The  membranes  must  be  ruptured  ;  (2)  the  os  must  be  dilated  or 
capable  of  dilatation  ;  (3)  there  must  be  no  obstruction  to  delivery  that 
we  cannot  reasonably  expect  to  overcome  ;  (4)  the  position  of  the  head 
must  be  positively  ascertained;  (5)  the  bladder  and  rectum  must  be 
empty. 

What  are  the  indications  for  their  use? 

Any  condition,  either  of  mother  or  child,  requiring  prompt  delivery. 
However,  the  most  frequent  cause  necessitating  forceps  delivery  is  inertia 
uteri. 

Describe  their  application. 

There  are  two  methods  of  applying  the  forceps.  One  is  called  the 
"cephalic  application,"  the  other  the  "pelvic."  In  the  former  the 
operator  introduces  the  blades  so  that  one  may  lie  on  each  side  of  the 
liead,  while  in  the  latter  they  are  introduced  on  the  sides  of  the  pelvis 
without  regard  to  the  position  of  the  foetal"  head. 

It  is  best  to  adopt  a  ]ilan  whereby  these  methods  may  be  combined. 
In  other  words,  if  the  head  lies  in  the  oblique  diameter  do  not  introduce 
the  blades  at  the  sides  of  the  pelvis,  but  one  a  little  posteriorly,  the  other 
anteriorly,  to  an  imaginary  transverse  plane  at  the  outlet.  The  applica- 
tion consists — (1)  of  their  introduction  ;  (2)  of  their  locking  ;  (3)  of  trac- 
tion ;  and  (4)  of  the  unlocking  and  removal. 

The  forceps  should  be  boiled  or  sterilized  after  each  usini!;,  that  they 
may  be  thoroughly  clean,  and  before  their  ai)plic:iti()n  placed  in  a  ])itcher 
containing  a  10  per  cent,  solution  of  warm  carbolic  a(;i(l.  The  bladder 
and  bowel  are  emptied,  a  vaginal  douche  given,  and  the  patient  placed 
at  the  edge  of  the  bed,  with  buttocks  at  right  angles  to  it.  Chloroform 
to  the  obstetrical  dcigrec;  only  is  generally  sufficient  in  "low  operations." 

The  blades  are  remov(Ml  from  the  solution  and  their  outer  surface  cov- 
ered with  sterilized  or  carbolized  vaseline  or  glycerin. 

The  left  blade  is  grasped  at  the  shank  between  i\w  fingers  and  thumb 
of  the  left  hand,  while  the  three  fingers  of  the  right  hand  are  introduced 


THE    FOECEPS. 


157 


on  the  left  side  of  the  vagina  until  they  come  in  contact  with  the  head. 
Hold  the  blade  at  jfirst  almost  perpendicularly  (Fig.  42) ;  then  pass  it 


Fig.  42. 


Introduction  of  First  Blade. 


along  the  palmar  surface  of  the  fingers,  gradually  depressing  the  handle 
as  the  instrument  passes  in,  until  by  the  time  its  introduction  is  complete 
the  handle  points  in  a  slightly  posterior  direction. 

The  handle  is  now  gently  held  by  an  assistant,  to  prevent  its  expulsion 
during  a  contraction  or  its  twisting  from  position  while  the  right  blade  is 


158 


OBSTETRIC   OPERATIONS. 
Fig.  43. 


Method  of  Tnf  roducing  Second  Blade. 


applied.     Tntrorlncin.ti  the  tliree  fingers  of  the  left  liand  on  the  mother's 
right  side,  this  is  passed  in  exaetly  the  same  way  (Fig.  43). 

Now  takmg  the  handles  with  the  two  hands,  they  are  gently  depressed 


THE    FORCEPS.  159 

toward  the  perineum,  and  the  lock  slii>s  into  position.  Always  see  that 
neither  a  small  fold  of  the  perineum  nor  any  hairs  are  caught  in  the 
lock. 

In  the  application  of  the  forceps  a  good  rule  to  i'ullow  is  this :  Use  the 
greatest  gentleness  and  care  in  the  introduction,  and  if,  this  being  done, 
they  slip  in  easily  and  lock  without  any  difficulty,  you  may  bo  sure  every- 
thing is  all  right  and  that  they  are  properly  applied.  If  the  slightest 
resistance  is  met  with  either  in  the  introduction  or  the  locking,  imme- 
diately withdraw  the  blades  and  reapply.  Introduce  the  blades  during 
the  intervals  between  the  pains. 

How  should  traction  be  made? 

Always  in  the  axis  of  the  parturient  canal,  and  intermittently.  Allow 
the  arm  to  rest  against  the  side  or  front  of  the  chest,  and  make  traction 
only  with  the  forearm  and  in  this  way :  With  the  palm  of  the  hand 
looking  upward,  the  index  finger  is  applied  to  one  shoulder,  the  second 
and  third  fingers  to  the  other,  the  shank  resting  in  the  crotch  between 
the  fingers.  When  a  pain  occurs  steady  traction  is  made,  first  in  a 
downward  direction,  later  in  a  horizontal  one,  and  as  the  head  emerges 
from  the  pelvis  in  an  upward  direction.  The  two  fingers  of  the  left 
hand  should  rest  against  the  descending  head  to  guard  against  the  possi- 
bihty  of  a  too  sudden  and  rapid  descent,  or,  if  it  is  necessary  to  exert  any 
compression,  this  hand  may  grasp  the  handles  of  the  instrument ;  but  as 
a  rule  this  will  not  be  called  for.  No  oscillatory  movement  of  the  handles 
is  necessary.     As  soon  as  the  contraction  ceases  discontinue  traction. 

When  should  the  blades  be  removed? 

In  ordinary  vertex  cases  as  the  head  begins  bulging  the  perineum  the 
forceps  should  be  removed,  as  there  is  always  danger  of  laceration  if  this 
is  not  done.  The  experience  of  a  few  forceps  deliveries  will  teach  us 
more  in  regard  to  the  proper  time  for  their  removal  than  description 
possibly  could.  If  the  maternal  condition  is  such  that  a  short  prolongation 
of  the  labor  might  be  injurious,  deliver  the  head  with  the  blades  still  ap- 
pHed.  The  same  may  be  said  in  regard  to  the  foetus.  If  the  heart  has 
stopped  beating  or  is  growing  slow  and  irregular,  a  rapid  delivery  is  in- 
dicated. 

The  after-coming  head  in  breech  cases  must  be  delivered  with  the  for- 
ceps applied. 

Describe  forceps  deliveries  with  the  occiput  posterior. 

In  these  cases  we  should  never  apply  the  forceps  until  Nature  has 
been  given  an  opportunity  of  causing  anterior  rotation,  or  at  least  until 
the  condition  of  mother  or  child  necessitates  their  use. 

The  instrument'  is  applied  in  exactly  the  same  maimer  as  already  de- 
scribed, and  traction  made  in  the  axis  of  the  pelvis  until  the  head  has 
reached  the  perineum.  It  will  often  be  found  at  this  time  that  rotation 
has  taken  place  within  the  blades,  or,  as  sometimes  happens,  the  instru- 


160  OBSTETRIC   OPERATIONS. 

merit  turns  with  the  head.  In  anj^  case  we  remove  the  blades  after  the 
head  has  descended  upon  the  perineum  and  give  Nature  another  chance. 
If  dehver}'  does  not  take  place,  they  may  be  reapplied,  and  now  the 
traction,  instead  of  being  made  upward,  must  take  place  backward 
toward  the  perineum,  as  the  face  should  be  born  first  under  the  sym- 
])h3'sis. 

Describe  the  high  forceps  operation. 

This  is  a  much  more  serious  and  difficult  procedure  than  the  low  ope- 
ration, and  in  a  majority  of  cases  version  may  be  much  more  easily  done. 
However,  cases  do  arise  where  it  seems  the  only  indication.  The  head 
will  lie  either  in  a  transverse  or  an  oblique  direction,  never  directly  antero- 
posteriorly,  so  that  one  blade  must  lie  over  the  occiput  and  the  other  by 
the  face  as  they  are  introduced  in  the  sides  of  the  pelvis. 

The  cervix  will  probably  be  not  completely  dilated,  and  the  head  may 
lie  so  high  up  that  it  becomes  necessary  to  introduce  the  whole  hand  into 
the  vagina,  passing  two  or  three  fingers  within  the  cervix  to  rest  against 
the  head,  which  is  steadied  by  the  hand  of  an  assistant  placed  over  the 
abdomen.  The  blades  are  applied  as  in  the  low  operation,  though  their 
application  is  usually  attended  with  much  more  difficulty.  The  same 
precautions  are  to  be  taken  in  locking  the  instrument.  Traction  must 
be  made  first  in  almost  a  backward  direction  ;  and  here  is  where  the  axis- 
traction  forceps  are  of  great  value.  Nevertheless,  the  ordinary  instru- 
ment may  be  used  in  these  cases,  though  always  with  much  more  diffi- 
culty. 

When  can  the  forceps  be  used  in  face  cases  ?  and  how  are  they 
applied  ? 

When  the  chin  points  either  anteriorly  or  to  one  or  the  other  side  of 
the  mother — never  if  posteriorly,  for  delivery  by  forceps  in  such  cases  is 
absolutely  impossible.  Their  application,  if  the  fronto-mental  diameter 
lies  in  conformity  with  the  antero-posterior  of  the  pelvis,  is  simi)ly  in  the 
sides  of  the  pelvis ;  but  if  it  lies  in  an  obli(iue  or  transverse  diameter, 
the  blades  must  be  applied  to  the  sides  of  the  child's  head  and  face. 

Traction  to  bring  the  part  down  on  the  perineum  is  generally,  as  in 
vertex  cases,  all  that  is  necessary.  If  complete  delivery  nuist  be  accom- 
))lislied,  simply  bear  in  mind  the  mechanism  in  these  cases  and  apply  the 
force  in  the  proper  direction. 

How  should  the  forceps  be  applied  to  the  after-coming  head  in 
breech  cases  ? 
To  the  sides  of  the  face  and  skull,  beneath  the  body  of  the  child,  if  an- 
terior rotation  of  the  head  has  taken  place.  If  not.  and  the  chin  is 
caught  above  the  symphysis,  the  body  nnist  be  raised  uj)  by  an  assist- 
ant, the  blades  apjAied  over  the  occipital  i)ortion  of  the  skull,  and  trac- 
tion made  in  an  anterior  direction  (the  handles  being  lifted  toward 
the  child's  back],  that  the  occiput  may  be  born  first. 


EMBRYOTOMY    AND    CRANIOTOMY.  161 

If  the  chin  rests  beneath  the  s^'mphj'sis,  make  the  traction  away  from 
the  back,  that  the  face  may  emerge  under  the  pubic  arch  first. 

Never  use  forceps  to  the  after-coming  head  until  all  other  methods  of 
deliver}"  have  failed. 

The  forceps  have  been,  and  are  still  by  some,  applied  to  the  breech. 
This  procedure  is  to  be  discouraged. 

What  are  the  dangers  of  forceps  operations  ? 

To  the  Mother. — In  low  operations,  if  properly  and  carefully  done,  there 
is  almost  no  risk,  and  much  less  harm  can  be  done  by  their  use  than  if 
the  foetal  head  is  allowed  to  rest  for  a  considerable  length  of  time  in  the 
pelvic  canal.  High  operations  are  naturalh"  attended  with  more  dan- 
gers, but  even  here,  if  the  cases  are  properly  chosen  and  intelligently 
treated,  the  dangers  are  not  great. 

The  unfortunate  results  attributed  to  the  forceps  are  injuries  to  the 
soft  parts  and  the  pelvis.  Among  the  former  are  lacerations  of  the 
uterus,  cervix,  vagina,  and  perineum,  sometimes  the  bladder,  urethra, 
and  rectum,  resulting  in  inflammatory  conditions,  fistulse,  and  sepsis. 
To  the  pelvis  both  fractures  of  its  bones  and  separation  of  the  joints  have 
occurred. 

To  the  Child. — Abrasions  of  the  skin  sometimes  occur,  but  are  of  no 
consequence  unless  they  are  so  extensive  and  deep  as  to  be  lacerations. 
They  are  usually  the  result  of  carelessness  or  ignorance.  Fractures  of  the 
cranial  bones,  cerebral  hemorrhages,  thrombosis  of  one  of  the  sinuses, 
and  death  have  all  been  caused  by  prolonged  and  severe  compression. 

What  is  the  vectis? 

A  short  curved  blade  resembling  one  of  the  blades  of  a  pair  of  short 
forceps.  It  was  formerly  used  to  promote  rotation  of  the  head  and  aid 
flexion,  but  has  been  entirely  discarded. 

What  is  the  fillet  ? 

It  is  a  loop  of  cloth,  metal,  or  whalebone  which  is  passed  over  the 
occiput  or  between  the  chin  and  thorax  of  the  foetus,  so  that  traction 
may  be  made.  It  is  sometimes  passed  over  the  groin.  It  is  never 
used  now. 

EMBRYOTOMY  AND   CRANIOTOMY. 

What  is  understood  by  these  two  terms? 

Embryotomy  is  applied  in  general  to  any  operation  requiring  the  de- 
struction of  the  foetus,  whether  this  be  a  simple  perforation  of  the  skull 
( ' '  craniotomy  " ) ,  perforation  with  crushing  ( ' "  cephalotripsy  " ) ,  crushing 
the  base  of  the  skull  ( "  basiotripsy  "),  or  the_  severing  of  the  head  or 
mutilation  of  the  foetus  ("decapitation,"  "  evisceration  "). 

Describe  the  instruments  generally  used  in  doing  embryotomy. 

(1)  Perforator. — Many  instruments  have  been  devised  for  perforation 
11— Obs. 


162  OBSTETRIC   OPERATIONS. 

of  the  skull,  but  in  a  general  way  they  consist  either  of  a  trephine  with 
a  long  handle,  sometimes  hollow  that  irrigation  may  be  resorted  to  and 
the  brain-substance  washed  out  of  the  skull,  or  of  scissors.  Those  sug- 
gested by  Smellie  or  some  modification  of  them  are  most  frequently 
used.  They  consist  of  a  long-handled  pair  of  scissors,  the  blades  of 
which  are  short  and  triangular,  the  apex  of  the  triangle  being  the  point, 
and  the  base  a  projecting  shoulder.  The  outer  edge  of  the  blades  only 
is  sharpened. 

(2)  Craniodast. — This  is  a  solid,  narrow-bladed  pair  of  forceps,  so 
designed  that  one  blade  may  be  introduced  through  the  perforation,  the 
other  kept  outside  of  the  skull.  When  both  are  introduced  they  are 
locked  like  the  forceps.  The  internal  blade  is  small,  non-fenestrated, 
and  convex,  while  the  external  is  larger,  fenestrated,  and  concave.  When 
locked  the  former  lies  against  the  internal  concave  surface  of  the  skull, 
while  the  latter  lies  against  the  external  convex  surfiee.  Thus  it  will  be 
seen  two  objects  may  be  accomplished — simple  traction,  or,  by  a  twisting 
movement,  a  breaking  off  of  portions  of  tlie  bones. 

(3)  Cephalotribr. — This  is  a  long,  solid  pair  of  forceps  with  a  com- 
pression-screw at  the  ends  of  the  handles.  The  blades  may  or  may  not 
be  fenestrated,  but  their  inner  surfaces  are  usually  serrated,  and  when 
applied  and  compressed  come  much  closer  together  than  do  the  ordinary 
forceps. 

(4)  Basiotrihe. — This  instrument,  first  devised  by  Tarnier,  is  very 
complete,  and  consists  of  both  perforator  and  cephalotribe  combined  in 
one. 

(5)  Crotchet. — This  is  a  sharp-pointed  hook  which  may  be  fastened 
on  some  portion  of  the  skull  and  traction  made  upon  the  handle.  It 
should  never  be  used  where  other  instruments  are  at  hand. 

State  the  indications  for  performing  craniotomy. 

In  a  general  way,  disproportion  between  the  head  and  the  parturient 
canal  is  the  usual  cause  re(iuiring  craniotomy,  and  this  most  frequently 
arises  from  deformity  of  the  pelvis. 

The  exact  amount  of  contraction  where  the  operation  is  justified  in 
preference  to  Caesarean  section  is  such  a  disputed  point  that  it  is  impos- 
sible to  lay  down  any  fixed  rule  to  be  followed  in  every  case.  Some  fix 
the  limits  of  the  operation  at  between  V\  and  o  inches  in  the  internal 
conjugate,  and  others  between  21  and  2|.  We  nuist  depend,  to  a  large 
extent,  upon  the  conditions  at  hand  for  the  performance  of  the  two  ope- 
rations, section  or  embryotomy.  If,  in  a  general  way,  the  chances  for 
the  mother  seem  much  better  by  destroying  the  foetus,  we  should  not 
hesitate  to  resort  to  this  procedure.  Other  causes,  such  as  hydroceph- 
alus, impacted  face  or  brow,  extended  after-coming  head,  rigid  .soft  parts 
of  the  maternal  passages,  cancer  of  the  cervix,  etc.,  have  already  been 
mentioned.  Some  recommend  the  oi)eration  in  all  cases  where  death  of 
the  foetus  is  positive,  but  as  this  is  always  a  questionable  point  to  decide, 
it  is  hardly  to  be  recommended. 


EMBRYOTOMY    AND    OHANIOTOMY.  163 

Describe  the  operation. 

After  the  preparation  of  the  patient,  operator,  and  assistants,  which 
slioiild  be  just  as  for  forceps  operations,  the  perforator,  carefully  guarded 
})y  the  fin.iicrs  to  prevent  injury  to  the  vaginal  wall,  is  passed  up  to  the 
head.  Here,  in  vertex  cases,  it  will  come  in  contact  with  one  of  the 
parietal  bones,  wliile  in  face  or  brow  presentations  it  should  be  intro- 
duced through  the  frontal  bone,  one  of  the  orbits,  or  the  roof  of  the 
mouth ;  and  in  case  the  after-coming  head  is  to  be  perforated,  it  must 
be  done  back  of  the  ear  or  to  one  side  of  the  foramen  magnum.  Pre- 
cautions must  be  taken  not  to  introduce  the  instrument  through  one  of 
the  sutures  or  fontanelles,  as  the  overlapping  oi"  the  bones  prevents  exit 
of  the  brain-substance  and  collapse  of  the  skull. 

An  assistant  grasps  the  foetal  head  firndy  through  the  abdominal  wnll 
to  steady  it,  and  the  perforator,  held  as  nearly  as  possible  at  right  angles 
to  the  bone  that  it  may  not  glide  off,  is  slowly  pushed  through  by  a  bor- 
ing motion.  When  the  shoulder  of  the  scissors  is  reached  the  handles 
are  separated.  This  opens  the  blades,  making  a  long  incision  in  the  cra- 
nium. Closing  the  instrument  again,  it  is  now  introduced  at  right  angles 
to  the  former  incision,  and  the  same  manoeuvre  repeated.  Then  push 
the  instrument  within  the  skull  as  far  as  the  base,  and,  moving  it  about, 
thoroughly  break  up  the  brain  tissue,  and  then  withdraw  it. 

Many  recommend  that  the  skull  should  now  be  washed  out  tlioroughly 
with  some  antiseptic  solution  before  ])roceeding  further,  but  this  is  un- 
necessary if  the  destruction  of  the  brain  has  been  carefully  done. 

The  completion  of  the  operation  consists  in  reducing  the  size  of  the 
head  and  delivering.  This  is  preferably  done  by  the  cephalotribe,  al- 
though it  may  be  necessary  to  break  up  the  vault  of  the  cranium  some- 
what with  the  cranioclast.  The  blades  of  the  instrument  must  be  deeply 
introduced,  that  the  base  of  the  skull  may  be  reached,  and  after  apply- 
ing, the  screw  on  the  handles  is  turned  slowly  and  the  bones  crushed. 
Delivery  is  then  accomplished  as  with  the  forceps,  though  it  may  be 
necessary  to  remove  and  reapply  the  instrument  once  or  twice  during  the 
operation. 

As  a  rule,  the  body  will  offer  no  difficulty  to  delivery,  though  excej)- 
tionally  further  mutilation  must  be  done. 

What  are  the  indications  for,  and  the  method  of,  decapitating? 

Impacted  shoulder  presentation,  in  which  the  child  is  jammed  far 
enough  into  the  pelvis  for  the  neck  to  be  within  reach. 

There  are  many  varieties  of  instruments  in  use  for  decapitating,  but 
tlie  one  which  has  gained  the  greatest  reputation  is  a  curved  steel  hook, 
the  internal  edge  of  which  is  sharpened.  This  is  passed  over  the  neck, 
and  by  a  backward  and  forward  movement  the  head  is  separated  from 
the  body. 

The  wire  ecraseur  has  also  been  somewhat  used,  as  has  also  a  jmir  of 
blunt  scissors.  Whatever  should  be  employed  must  be  used  with  the 
greatest  care,  that  injury  to  the  maternal  structures  be  avoided. 


164  OBSTETRIC   OPERATIONS. 

As  soon  as  completely  severed  the  head  is  pushed  up  into  the  uterus 
and  the  bod}'  withdrawn  by  dragging  down  upon  the  arm.  The  head 
remains  to  be  delivered,  and  this  can  generally  be  done  by  crowding  it 
down  into  the  pelvis  by  abd(jminal  pressure  and  applying  the  forceps,  or 
preferably  the  cephalotribe.  If  not,  it  must  be  perforated,  and  under 
the  circumstances  the  operation  is  not  an  easy  one. 

When  should  evisceration  be  resorted  to?    Describe  the  opera- 
tion. 

Occasionally  after  craniotomy  where  resistance  is  encountered  in  de- 
livering the  body,  most  frequently  in  impacted  shoulder  presentations 
where  the  neck  lies  high  up  beyond  reach. 

The  most  dependent  part  of  the  thorax  is  penetrated  by  a  strong  pair 
of  scissors,  the  thoracic  viscera  broken  up  and  withdrawn  in  pieces. 
Next  the  diaphragm  is  cut  through,  and  the  contents  of  the  abdominal 
cavity  removed.  This  will  allow  the  body  to  collapse,  and  to  be  born  as 
in  spontaneous  evolution.  It  is  said  that  if  the  spinal  column  be  divided 
with  a  strong  pair  of  scissors  passed  through  the  opening  in  the  thorax, 
the  delivery  is  easier,  as  the  child  is  folded  as  it  were  upon  itself.  For 
its  removal  the  crotchet  or  blunt  hook  may  be  used. 

The  dangers  to  the  mother  of  any  of  the  above- described  operations 
are  evident,  unless  the  greatest  care  and  antiseptic  precautions  are  ob- 
served, when  naturally  they  become  materially  lessened. 

An  intra-uterine  irrigation  of  a  bichloride-of-mercury  solution,  1  :  5000, 
followed  by  a  prolonged  douche  f intra-uterine)  of  thoroughly  sterilized 
warm  water,  should  be  given  in  every  case  where  either  the  hand,  lingers, 
or  any  instrument  has  been  introduced  into  the  uterine  cavity. 

The  after-treatment  does  not  differ  from  that  following  a  normal  de- 
livery. 

THE  CuESAREAN  SECTION  AND  ITS  MODIFICATIONS. 

What  is  the  Caesarean  section? 

It  is  an  operation  consistinu  in  cutting  through  the  abdominal  wall  and 
the  uterus,  and  removing  the  child  through  the  wound  thus  made. 
There  are  several  modifications  of  the  operation  :  (1 )  The  Porro,  in  which 
the  uterus  is  amputated,  with  its  appendages,  at  the  cervix,  after  the 
removal  of  the  child  ;  and 

(2)  The  Porro- M tiller,  which  is  a  modification  of  the  above,  and  con- 
sists in  lifting  the  uterus  out  of  the  abdominal  wound,  constricting  the 
cervix  to  prevent  hemorrhage,  then  incising  the  organ,  removing  the 
child,  and  amputating  as  in  the  above. 

What  are  the  indications  requiring  the  operation? 

Delbrmities  of  the  pelvis,  where  the  dauiiers  of  craniotomy  would  be 
greater  to  the  mother  than  laparotomy ;  malignant  tumors  of  the  cervix 
or  uterus;  tumors  o})structing  the  pelvis  and  rendering  delivery  in  this 
way  impossible ;  occlusions  of  the  vagina,  rendering  delay  dangerous  or 


THE   CESAREAN   SECTION   AND    ITS   MOT  IFIGATIONS.       1 65 

impossible ;  some  cases  of  impacted  transverse  presentations,  with  per- 
haps only  slight  pelvic  deformity  ;  death  of  the  mother  during  the  latter 
months  of  gestation  or  during  labor.  Children  have  been  saved  where 
the  operation  was  done  soon  after  death. 

Is  it  possible  to  make  a  prognosis  as  to  the  result? 

It  is  not,  as  the  success  or  failure  of  the  operation  must  depend  upon 
so  many  conditions.  The  general  health  of  the  woman,  the  experience 
of  the  operator,  the  })reparations  and  surroundings  of  the  patient,  and, 
above  all,  whether  or  not  the  operation  is  one  of  election  and  the  time  is 
chosen  or  one  of  necessity,  make  a  prognosis  favorable  or  unfavoraVjle  as 
the  case  may  be. 

If  the  patient's  condition  is  good,  the  time  for  operating  properly 
chosen,  and  the  surroundings  favorable,  the  mortality  is  not  over  25  per 
cent.  The  usual  causes  of  death  are  shock,  hemorrhage,  exhaustion, 
peritonitis,  metritis,  and  septicaemia.  There  is  little  or  no  danger  to  the 
child. 

When  should  the  operation  be  done  ?    Describe  the  simple  sec- 
tion. 

It  is  now  generally  admitted  that  the  best  time  for  operating  is  after 
labor  has  begun,  for  two  reasons :  First,  the  uterine  contractions  prevent 
hemorrhage ;  and  secondly,  free  drainage  of  the  lochia!  discharge  is  ob- 
tained, as  the  cervix  is  somewhat  dilated.  Some  think  it  is  just  as  well 
to  induce  labor  near  full  term  ;  others  prefer  having  everything  in  readi- 
ness and  waiting  until  it  normally  occurs. 

Prqmrations.— -The  room  for  the  operation  should  be  large,  well  ven- 
tilated, and  well  lighted  both  by  natural  and  artificial  lights,  as  it  may  be 
necessary  to  operate  at  night.  All  furniture  is  to  be  removed,  and  the 
floors,  walls,  and  ceilings  washed  with  a  1 :  500  solution  of  bichloride  of 
mercury. 

As  term  approaches,  provided  it  has  been  decided  to  defer  the  opera- 
tion until  this  time,  the  patient's  bowels  must  be  kept  open  by  the  use 
of  laxatives  or  enemas,  and  some  mildly  antiseptic  vaginal  douche  given 
once  daily. 

As  soon  as  labor  begins  the  abdomen  and  suprapubic  regions  must  be 
shaved,  thoroughly  scrubbed  with  soap  and  warm  water,  afterward  washed 
with  alcohol  and  ether,  and  then  with  a  solution  of  bichloride,  1  :  1000. 
A  large  folded  compress  of  gauze,  sufficient  to  cover  the  entire  abdomen, 
is  wrung  out  of  the  same  solution  and  held  in  place  by  an  abdominal 
binder  loosely  applied.  This  will  not  be  removed  until  the  first  incision 
is  about  to  be  made.  Always  pass  the  catheter  the  last  thing  before  the 
operation  is  begun.  The  anaesthetic  to  be  given  is  a  matter  of  choice. 
Many  prefer  chloroform,  as  there  is  much  less  danger  of  vomiting  after- 
ward. At  least  two  or  three  assistants  are  needed,  besides  the  one  ad- 
ministering the  anaesthetic. 

Plenty  of  sterilized  hot  water  must  be  at  hand,  as  well  as  ice,  alcohol, 


166  •  OBSTETRIC   OPERATTOXS. 

etc.;  for  resuscitating  the  child.  The  instruments,  sutures,  needles,  etc. 
must  be  carefully'  sterilized  and  kept  subnierued  in  a  :^j  per  cent,  solution 
of  carbolic  acid. 

The  operator  stands  on  the  patient's  right  side,  one  assistant  at  her 
left,  another  at  the  foot  of  the  table,  and  if  a  third  be  at  hand  he  will 
pass  instruments,  needles,  etc.  Begin  the  operation  when  the  cervix  is 
slightly  dilated. 

The  Operation. — With  a  scalpel  the  abdominal  incision  is  made  in  the 
median  line,  to  extend  from  an  inch  or  two  above  the  umbilicus  to  within 
the  same  distance  from  the  symphysis  ])ubis.  The  skin  and  fascia?  arc 
cut  until  the  peritoneum  is  reached.  All  bleeding  must  now  be  stopped 
by  clamps,  and  liuatures  if  necessary.  An  opening  is  then  made  in  the 
peritoneum,  the  first  two  fingers  of  the  left  hand  passed  through  it,  and, 
using  them  as  a  guide,  this  is  opened  throughout  the  length  of  the  ab- 
dominal wound  with  a  pair  of  blunt-pointed  scissors. 

The  parts  now  retract  over  the  uterus,  exposing  this  organ.  Towels 
wrung  out  of  hot  water  must  be  placed  around  the  wound,  and  the  as- 
sistant places  a  hand  on  each  side  of  the  uterus  to  steady  it  and  hold  it 
up  in  apposition  with  the  abdominal  wound  while  the  operator  opens  it. 
Some  rupture  the  membranes  p'!'?'  vaghuan  at  the  beginning  of  the  ope- 
ration, while  others  do  it  through  the  incision.  An  opening  is  now  made 
in  the  median  line  of  the  uterus,  and  the  incision  extended  with  scissors, 
following  the  same  method  pursued  in  dividing  the  peritoneum.  The 
membranes  are  ruptured,  if  this  has  not  already  been  done,  and  the  child 
lifted  out  and  given  into  the  hands  of  an  assistant.  The  cord  is  then 
clamped  and  cut. 

The  placenta  may  become  detached  as  contraction  occurs,  or  may  have 
to  be  removed.  In  either  case  the  cavity  of  the  uterus  is  sponged  out 
and  the  sutures  introduced.  About  this  time  a  full  dose  of  ergotin 
should  be  administered  hypodermically.  It  sometimes  happens  in  open- 
ing the  uterus  that  the  placenta  lies  immediately  beneath  the  incision, 
in  which  case  we  may  cut  directly  throuirh  it.  Hemorrhage  will  be  more 
profuse,  but  generally  controllable.  It  rarely  becomes  so  free  as  to 
necessitate  the  use  of  styptics. 

The  uterine  wound  is  closed  by  two  lines  of  sutures.  Silk,  wire,  and 
catgut  are  all  used,  but  preference  is  given  to  the  first.  The  deep  sutures 
are  passed  through  tlie  muscular  tissue  down  to  the  mucous  lining,  about 
I  to  J  an  infh  ai)art.  and  in  each  interspace  is  placed  a  superficial  suture. 

The  abdominal  cavity  must  now  be  cleansed  with  sponges,  and  the 
wound  in  the  a})dominal  wall  closed.  This  may  be  done  either  with  sil- 
ver wire  or  silkworm  gut,  as  after  an  ordinary  laparotomy  or  ovariotomy. 
The  external  dressing  consists  of  dusting  the  wound  with  iodoform,  cov- 
ering it  with  a  strip  of  iodoform  yauze,  and  over  this  bichloride  gauze, 
absorbent  cotton,  and  a  binder  to  liold  the  dressing  in  place. 

The  (ifti'i-'trcafmrut  consists  in  absolute  rest  in  the  dorsal  position, 
morphine  hypo<lermically  to  relieve  pain  and  restlessness,  small  quanti- 
ties of  cracked  ice,  water,  and  iced  chami)agne  at  frequent  intervals,  and 


THE   CESAREAN   SECTIOX    AND    ITS    MODIFICATIONS.       167 

catheterization  every  six  or  eight  liours.  x\t  the  end  of  twelve  hours,  if 
there  be  no  nausea  or  vomiting,  peptonized  milk,  beef  tea,  or  mutton 
broth  may  be  given  in  small  quantities.  After  two  or  three  days  the 
bowels  may  be  moved  by  an  enema  of  soapsuds.  If  no  unfavorable 
symptoms  occur,  the  dressing  should  not  be  removed  for  ten  or  twelve 
da.vs,  when  the  sutures  are  taken  out. 

Describe  the  Porro  operation. 

In  this  operation  the  same  course  described  above  is  pursued  until 
after  the  removal  of  the  child  and  secundines.  When  this  is  done  the 
uterus  is  lifted  out  of  the  abdominal  cavity,  an  elastic  tubing  passed 
around  the  cervix  and  tightened  until  all  hemorrhage  has  ceased,  and 
then  amputated  just  above  the  ligature,  the  stump  drawn  up  through 
the  wound,  cauterized  by  the  Paquelin  cautery,  and  fastened  in  the  ab- 
dominal wound  either  by  sutures  or  pins. 

Describe  the  Porro-Muller  operation. 

This  diifers  from  the  former  only  in  one  way ;  that  is,  the  Hfting  of 
the  uterus  from  the  abdominal  cavity  before  incising.  This  is  done  diat 
all  possibility  of  the  escape  of  fluid  into  the  peritoneal  and  abdominal 
cavities  be  prevented.  As  soon  as  lifted  out  hot  towels  are  wrapped 
around  it,  and  sponges  placed  about  the  wound  to  absorb  all  fluids 
(liquor  amnii  and  blood). 

Many  in  the  simple  section  resort  to  this  procedure,  afterward  re- 
placing the  organ  in  the  abdominal  cavity. 

What  is  Sanger's  method  ? 

Abdominal  incision  as  described;  then  lift  the  uterus  from  the  cavity, 
apply  two  or  three  sutures  at  the  upper  angle  of  the  abdominal  wound 
to  close  it  about  the  uterus,  and  make  compression  at  the  cervix.  The 
organ  is  then  opened  and  the  child  removed.  The  peritoneum  is  now 
dissected  from  the  muscular  edges  of  the  uterine  wound,  and  a  long,  nar- 
row, wedge-shaped  piece  of  tissue  taken  from  the  muscular  coat.  The 
peritoneum  is  then  turned  down  over  the  muscular  layer  and  deep 
sutures  introduced.  Then  the  serous  surfaces  of  the  peritoneum  are 
brought  together  by  superficial  sutures. 

The  choice  of  operation  must  depend  entirely  upon  the  condition  of 
affairs  present  and  the  judgment  of  the  operator. 

What  can  you  say  of  the  post-mortem  Csesarean  section  ? 

It  should  be  done  in  every  case  of  death  of  mother  after  viability  of 
the  child  if  it  can  be  done  soon  after  death.  The  probabilities  are  that 
if  half  an  hour  or  more  has  passed  the  foetus  will  have  perished. 

Describe  laparo-elytrotomy. 

It  is  an  operation  by  which  the  child  is  delivered  through  the  abdomen 
of  the  mother  by  way  of  the  cervix  and  upper  part  of  the  vagina.  The 
incision  is  made  in  the  lower  part  of  the  abdominal  wall,  and  the  peri- 


168  OBSTETRIC   OPERATIONS. 

toneal  cavity  is  not  opened.  The  primary  preparation  of  the  patient  is 
to  be  as  for  the  Caesarean  section.     The  os  must  be  fully  dilated. 

An  incision  is  made  on  the  right  side  parallel  with  Poupart's  liga- 
ment, and  about  5  inches  in  length,  passing  from  1 1  inches  above  and 
to  the  outside  of  the  spine  of  the  pubes  to  the  same  distance  above  the 
anterior  superior  spinous  process  of  the  ilium.  The  muscles  are  care- 
fully divided  and  the  peritoneum  exposed.  This  is  gently  loosened  from 
the  fasciae  and  lifted  upward.  The  vagina  then  becomes  exposed  as  the 
peritoneum  and  intestines  are  held  away  by  an  assistant.  Another 
assistant  draws  the  uterus  to  the  left,  so  that  the  right  side  of  the 
vagina  is  exposed.  A  third  introduces  the  female  catheter  into 
the  bladder  ' '  as  an  indicator  and  to  lift  the  viscus  from  the  vagina. ' ' 
A  blunt  wooden  rod  is  passed  into  the  vagina,  and  by  it  the  wall  is 
pushed  up  into  the  incision.  An  incision  is  now  made  in  the  vagina 
over  the  rod  with  a  thermo-cautery,  a  galvano-caustic  knife,  or  a  small 
puncture  with  the  bistoury  is  enlarged  by  tearing  with  the  fingers.  The 
catheter  is  now  removed  and  the  membranes  ruptured.  Delivery  may 
take  place  through  the  wound  by  contractions  of  the  uterus,  but  will 
usually  have  to  be  accomplished  by  version  or  the  forceps. 

The  placenta  is  delivered  by  Credo's  method.  The  uterus  and  vagina 
are  now  thoroughly  irrigated,  and  the  abdominal  wound  closed  and 
dressed  antiseptically. 

This  operation  has  been  little  done  during  the  past  few  years,  since  the 
Caesarean  section  has  become  so  much  more  successful. 

What  is  symphysiotomy? 

It  is  an  operation  devised  by  Sigault  of  Angers,  and  consists  in  a  di- 
vision of  the  symphysis  pubes,  that  the  bones  may  separate  sufficiently 
to  allow  the  passage  of  the  head.  Little  space  is  gained  by  the  opera- 
tion, and  under  no  circumstances  is  it  ever  indicated. 

TRANSFUSION  AND  INFUSION. 

What  is  transfusion  of  blood  ?  and  when  is  it  indicated  ? 

It  is  the  act  of  passing  blood  from  one  person  or  animal  into  the  veins 
of  another,  and  is  indicated  as  a  last  resort  in  cases  of  severe  hemor- 
rhage. 

The  transfusion  may  be  direct  from  the  vein  of  the  donor  to  that  of 
the  receiver,  or  it  may  be  first  drawn  and  afterward  injected.  If  the 
latter  is  done,  something  must  be  added  to  the  blood  to  prevent  coagu- 
latioji,  or  it  must  be  defibrinated  by  beating  and  then  strained,  that  only 
the  fluid  part  may  be  injected. 

Describe  the  process  of  direct  transfusion. 

Numerous  apparatuses  have  been  devised  for  this  purpose,  but  all  are 
open  to  criticism. 
Aveling's  apparatus  has  probably  been  more  generally  used  than  any 


PUERPEEAT.   DISEASES.  169 

other.  It  consists  of  a  small  bulb  sjTinge  without  valves  and  having  a 
silver  canula  at  each  end.  One  is  inserted  in  one  of  the  veins  of  the  arm 
of  the  donor  (usually  the  median  basilic),  the  other  in  the  corresponding 
vein  in  the  arm  of  the  receiver,  and  the  blood  carried  from  one  to  the 
other.  Transfusion  from  artery  to  artery  has  also  been  done.  The  cur- 
rent is  apt  to  be  sluggish  and  perhaps  coagulate,  the  physician  usually 
inexperienced,  and  for  this  reason  direct  transfusion  is  not  often  done. 
3Iore  freciuently  is  the  blood  withdrawn,  defibrinated.  heated  to  the 
proper  temperature,  and  then  injected. 

The  injection  of  warm  fresh  cows  milk  into  the  veins  in  cases  of  hem- 
orrhage has  also  been  used,  but  without  any  great  success.  This  is  called 
infusion. 

What  is  infusion  ? 

The  passing  into  the  circulation  of  a  saline  solution  of  milk  through 
one  of  the  veins.  It  is  indicated  in  the  same  cases  in  which  transfusion 
is  done,  and  has  met  with  more  success  than  it.  Little's  solution,  which 
is  often  used,  is  made  up  of — 

Chloride  of  sodium,  5j ; 

Chloride  of  potassium,  gr.  vj  ; 

Phosphate  of  sodium,  gr.  iij  ; 

Carbonate  of  sodium,  er.  xx  ; 

Water,  |xx.— M. 

This  must  be  heated  to  a  temperature  of  99°  or  100°  F.,  and  10  to  12 
ounces  at  a  time  slowly  injected  into  one  of  the  veins  of  the  arm,  care 
being  taken  that  no  air  enter  with  it. 


CHAPTER   YIII. 

PUERPERAL   DISEASES. 

PUERPERAL   INFECTION. 

How  may  puerperal  infection  manifest  itself? 

As  an  infectious  disease  with  violent  constitutional,  but  no  marked 
local,  symptoms,  or  with  less  marked  constitutional,  but  severe  local, 
symptoms,  or  both  may  be  greatly  developed.  Septicaemia  and  childbed 
or  puerperal  fever  are  names  usually  given  to  the  disease  when  the  consti- 
tutional symptoms  predominate,  while  if  local  symptoms  are  marked  it 
becomes  a  puerperal  or  septic  peritonitis,  metritis,  endometritis,  phlebitis, 
etc. ,  as  the  case  may  be. 


170  PUERPERAL    DISEASES. 

When  does  infection  usually  takes  place  ?  and  how  ? 

Usually  within  the  two  or  three  daj-s  following-  confinement,  though 
cases  do  occur  as  late  as  twelve  days.  However,  if  seven  or  eight  days 
be  passed  free  from  infection  there  is  good  reason  to  believe  that  it  will 
not  occur. 

The  point  of  infection  may  be  at  the  vulva  from  abrasions  or  lacera- 
tions in  this  vicinity,  within  the  vaginal  canal,  at  the  cervix,  or  in  the 
uterus.  When  infection  takes  place  within  this  organ,  it  is  at  the  site 
of  placental  attachment.  The  poison  enters  through  freshly-wounded 
surfaces  ;  therefore  the  dangers  are  over  when  these  are  covered  by  gran- 
ulations, as  such  a  surface  is  non-absorptive. 

What  is  the  poison  causing  infection  ?  and  how  carried  ? 

It  is  now  considered  to  be  the  same  as  that  which  produces  septicaemia 
or  p3'aemia  in  ordinary  surgical  cases,  and  is  a  micrococcus  or  germ. 
Formerly  the  cases  were  classified  as  heferor/enefic,  or  those  in  which  the 
poisdu  was  introduced  from  without  the  body,  and  mitogenetic,  when 
develojied  within  the  body  of  the  woman.  This  distinction  is  not  now 
generally  admitted,  as  no  poison  can  be  formed  within  the  woman  with- 
out some  infective  germ  entering  from  outside  the  body.  This  poison 
may  arise  from  decom])osing  organic  matter  or  tissues,  putrefactive 
changes  without  or  within  the  body,  cadaveric  poison,  and  probably 
from  many  of  the  zymotic  diseases. 

The  pregnant  woman  is  very  liable  to  infection,  both  from  her  condi- 
tion during  gestation  and  the  exhaustion  (and  perhaps  anaemia)  following 
delivery.  The  infection  is  most  frequently  carried  by  the  doctors,  nurses, 
or  midwives  on  the  hands  or  instruments,  though  it  may  reach  the  i)ar- 
turient  canal  through  the  air  in  lengthy  exposures  of  the  vulva  during 
the  changing  of  the  vulvar  pad  or  the  use  of  the  bed-pan. 

PATHOLOGY. 

What  can  you  say  of  the  pathology  of  the  following  diseases  ? 

Of  Vaginitia. — There  is  a  swelling  and  extreme  tenderness  of  the 
vaginal  mucous  membrane,  a.ssociated  with  heat,  redness,  and  a  i>urulent 
di.scharge.  There  may  be  areas  of  necrotic  or  ulcerative  tissue,  and 
these  are  sometimes  covered  by  a  di|>htherit.ic  membrane.  Or  this 
membrane  may  appear  on  an  ai)parently  healthy,  unabraded  surface. 

Of  Endometritis  (tnd  Metritis. — As  a  rule,  both  occur  togetlier.  The 
endometrium  is  swollen,  red.  and  may  contain  areas  of  ulceration.  The 
discharge  I'rom  the  uterus  is  putrid  and  offensive.  The  organ  itself  is 
enlarged,  and  its  muscular  tissue  infiltrated  with  pus,  or  it  may  contain 
gangrenous  areas,  or  be  the  seat  of  diphtheritic  dei)osits. 

Of  CelluJitis. — Any  of  the  connective  tissue  about  the  uterus  may  be- 
come the  seat  of  inflanmiation.  It  is  .swollen  and  infihrated.  Some 
localized  peritonitis  is  generally  a.ssociated  with  it,  and  adhesions  form. 
It  may  resolve  without  the  formation  of  an  abscess,  but  many  times  does 


PUERPERAL    INFECTION. — SYMPTOMS.  171 

not.  This  abs(;(!ss  may  point  and  o])cn  in  sonic  portion  of  the  vagina,  in 
tlie  bowcil,  or  in  tho  bladfler,  or  it  may  open  externally  in  the  ,<iroin  or 
throiiirh  the  alxlominal  wall. 

Of  Per'dnnith. — It  may  he  ireneral  or  local.  In  the  latter  case  it  is 
usually  associated  with  inflammatory  conditions  of  some  of  the  pelvic 
or,irans,  and  is  confined  to  the  pelvic  pcritoncnim.  The  membrane  is 
thickened,  and  small  areas  are  covered  with  a  fibrinous  exudate.  The 
intestines  or  pelvic  organs  may  be  bound  together,  and  in  the  cavity  of 
the  peritoneum  is  found  a  purulent  or  serous  fluid. 

Of  PhJehitk. — The  veins — perhaps  of  the  uterus,  possibly  elsewhere 
in  the  bod}^ — become  thickened  and  their  inner  surface  roughened. 
Thrombosis  occurs,  the  clots  may  become  disorganized,  and  pus  is 
formed,  or,  as  sonietimes  happens,  the  clot  becomes  organized,  forming 
new  connective  tissue.  When  pus  is  formed,  it  may  be  carried  by  the 
circulation  to  other  parts  of  the  body,  causing  the  same  process  to  be 
gone  through  here.  These  are  the  so-called  pysemic  abscesses,  which  are 
most  frequently  found  in  the  lungs,  joints,  liver,  kidneys,  spleen,  and 
heart. 

Of  Acute  Scpticaniia. — Death  in  these  cases  usually  occurs  so  rapidly 
that  none  of  the  changes  already  described  will  occur.  The  only  thing 
found  is  the  morbid  condition  of  the  blood.  It  is  dark  in  color,  thin, 
and  does  not  readily  coagulate.  The  red  cells  are  diminished  in  number, 
while  there  is  an  increase  of  the  white.     It  may  have  an  offensive  odor. 

SYMPTOMS. 

Describe  the  symptoms  of  puerperal  infections. 

Depending  upon  the  severity  of  the  infection  and  the  parts  or  organs 
involved,  the  si/m2ytorns  vary.  In  acute  septicaemia,  without  local  in- 
flammations, there  occurs  shortly  (within  a  few  hours  or  a  day  or  two) 
after  labor  a  violent  chill,  followed  by  a  rise  of  temperature  to  103°,  104°, 
10f)°  F. ,  or  even  higher.  The  face  is  pale  and  anxious,  the  tongue 
heavily  coated,  and  moist  at  first,  soon  becoming  dry,  brown,  and  hard ; 
the  pulse  is  rapid,  feeble,  and  may  be  irregular.  There  is  no  abdominal 
pain  or  tenderness,  and  maybe  no  tympanites.  The  respirations  are 
rapid  and  shallow,  and  there  is  generally  a  severe  diarrhoea.  Delirium, 
stupor,  or  coma  may  follow,  ending  in  death.  The  urine  is  scanty  in 
amount,  contains  albumin,  and  perhaps  some  hyaline  casts.  The  lochia 
may  be  suppressed  or  may  be  of  a  dark  color  and  extremely  offensive. 
Vomiting  may  or  may  not  be  present.  The  secretion  of  milk,  if  this 
has  begun,  is  arrested.  Death  generally  occurs  within  a  short  time, 
though  occasionally  the  patient  passes  into  the  typhoid  condition  and 
lingers  for  a  week  or  two. 

With  any  of  the  local  manifestations  all  the  above  symptoms  mai/  be 
present,  though  usually  not  as  markedly  d('velo])ed. 

Vaginitis, — Constitutional:    Chill  or  chilly  sensations;    temperature 


172  PUERPERAL    DISEASES. 

102°  to  U)4°  F.,  and  usuall}^  higher  evenings;  pulse  rapid;  loss  of  ap- 
petite ;  headache  ;  maybe  nausea  and  vomiting. 

Local :  Swelling,  redness,  and  pain ;  painful  micturition  and  defeca- 
tion ;  lochial  discharge  offensive ;  ulcers  or  diphtheritic  membrane  in 
some  cases. 

These  cases  may  be  very  mild,  under  which  circumstances  the  temper- 
ature slowly  falls,  constitutional  symptoms  disai)[)ear.  and  recovery  takes 
place  within  a  couple  of  weeks ;  or  they  may  be  very  severe,  in  which 
case  there  is  likely  to  be  a  sloughing  of  the  entire  vaginal  canal  before 
death  occui-s. 

Endometritis  mid  Metritis. — Constitutional :  Chilly  sensations,  or  these 
may  be  absent ;  moderate  rise  of  temperature,  101°  to  103°  F.  ;  loss  of 
appetite,  coated  tongue,  and  headache  ;  pulse  slightly  accelerated.  There 
may  be  diarrhoea. 

Local :  Pain  and  tenderness  over  the  uterus ;  enlargment  of  this  organ ; 
cervix  patulous  and  oedematous;  lochia  bright-red  and  offensive.  If 
necrosis  of  the  tissues  occurs  or  a  diphtheritic  process  be  present,  the 
symptoms  are  much  more  severe. 

6V//?<//^/.s.— Constitutional :  Chill  generally,  but  perhaps  only  cold  sen- 
sations; temperature  102°  to  105°  F.  ;  pake  rather  rapid;  headache, 
anorexia,  and  prostration ;  maybe  vomiting  and  diarrhcea. 

Local :  Pain  generally  to  one  side  of  the  uterus,  and  sometimes  ex- 
tending down  the  thigh ;  lochia  normal  or  foetid.  On  vaginal  exam- 
ination a  swelling  is  found  on  one  side  of  the  uterus,  occasionally  push- 
ing this  organ  to  the  opposite  side.  The  uterus  is  large,  and  when 
moved  severe  pain  results.  The  leg  may  become  oedematous.  This 
condition  either  goes  on  to  resolution  or  an  abscess  forms,  perforating  as 
mentioned.     The  opening  may  now  close  or  a  sinus  remain. 

Tlie  differential  duignoHis  between  this  condition  and  pelvic  peritonitis 
is  always  very  difficult.  Cellulitis  usually  l^egins  on  one  side  only,  and 
extends  downward  by  the  side  of  the  vagina,  while  a  peritonitis  is  most 
fref|uently  found  posteriorly  in  Douglass  pouch. 

Peritonitis.— [\)  GVxr/vr/.— Constitutional :  Severe  chill,  followed  by 
temperature  of  103°  to  105°  F.  ;  pulse  very  rajjid.  thready,  and  usually 
high-tensioned ;  respiration  rapid  and  shallow  ;  tongue  coated,  dry,  and 
brown;  face  flushed  and  anxious;  ihii-st  exces.sive ;  vomiting,  almost 
continuous,  soon  becomes  greenisli.  and  maybe  frecal.  Diarrhoea  gene- 
rally not  marked.  The  urine  is  scanty,  high-colored,  and  contains  albu- 
min ;  may  be  suppressed.  Hiccoughs  constantly.  Pain  is  constant,  ex- 
cruciating, and  confined  to  the  abdomen.  Patient  lies  on  her  back  with 
the  knees  drawn  up.     There  may  be  delirium  or  stujtor  preceding  death. 

Local :  Tympanites  general  and  marked,  lochia  suppressed,  or  may  be 
present,  and  fjetid  ;  the  vagina  is  hot  and  dry. 

(2)  Load. — All  the  above  symi)toms  may  be  present,  but  generally 
not  to  such  a  marked  degree.  The  lochia  will  be  scanty,  and  usually 
offensive.  Pressure  in  one  of  the  vaginal  fornices  elicits  severe  pain, 
and  often  late  in  the  disease  the  pelvic  organs  are  found  matted  togetlier. 


PUERPERAL   INFECTION. — TREATMENT.  173 

PMeJnfh9.—Chi\\;  rise  of  temperature,  ]01°  to  103°  F.,  then  a  pro- 
fuse perspiration.  The  temperature  assumes  a  remittent  character. 
The  pulse  is  accelerated ;  tongue  coated ;  anorexia ;  headache ;  diar- 
rhoea. 

These  may  be  all  the  general  symptoms  developed,  unless  an  infective 
thrombus  or  pus  is  carried  to  some  other  part  of  the  body.  Tn  this  case 
pyaemia  results.  Chills  are  fre((uent  and  terrible,  and  always  followed 
by  a  high  temperature,  1(J4°  to  110°  F.  ;  sweating  profuse;  pulse  small, 
rapid,  and  feeble  ;  tongue  brown  ;  pain  in  some  of  the  joints,  associated 
with  swelling,  redness,  and  oedema.  The  presence  of  pus  here  may  cause 
fluctuation,  delirium,  stupor,  or  coma.  Symptoms  referable  to  special 
organs  may  be  present  as  these  become  involved.  Thus  we  find  pneu- 
monia, endocarditis,  pleurisy,  pericarditis,  nephritis,  etc. 

Is  the  prognosis  always  unfavorable  in  puerperal  infection? 

It  is  not,  though  it  must  necessarily  cause  very  grave  anxiety  on  the 
part  of  the  physician.  In  the  acute  form  of  septicaemia  recovery  is  very 
rare.  If  the  constitutional  symptoms  are  not  severe,  we  have  reason  to 
believe  that  the  infection  is  not  great,  and  hence  our  prognosis  must  be 
more  favorable. 

The  prognosis  of  cellulitis,  local  peritonitis,  vaginitis,  and  metritis  is 
best.  The  most  unfavorable  symptoms  are  uncontrollable  vomiting  or 
diarrhoea,  a  very  rapid  and  feeble  pulse,  high  temperature,  extreme 
prostration,  and  a  very  offensive  lochia. 

What  is  the  treatment? 

(1 )  Prophylactic. — This  consists  in  paying  the  strictest  attention  to 
cleanliness  and  antisepsis  during  labor  and  the  puerperal  state,  and  to 
the  proper  selection  of  the  room,  bed,  bedding,  etc.  for  the  confinement 
and  the  puerperal  state.  All  these  have  been  spoken  of  Do  not  attend 
a  confinement  when  caring  for  a  septic  or  contagious  case. 

(2)  Curative. — First,  bear  in  mind  the  fact  that  infection  has  entered 
the  system  in  some  way,  and  if  possible  learn  how,  that  further  absorp- 
tion may  be  prevented.  Secondly,  sustain  the  vitality  of  the  patient  by 
proper  food  and  stimulation  until  the  effects  of  the  poison  have  ])assed 
off. 

If  the  slightest  rise  of  teniperature  occurs  in  the  puerperal  woman,  or 
if  the  lochial  discharge  acquires  the  faintest  odor,  niake  a  thorough  ex- 
amination. Find  out  Avhether  there  be  any  tenderness  over  the  abdo- 
men, and  examine  the  vulva  for  a  pathological  condition  here.  Such  an 
examination  revealing  nothing,  a  vaginal  examination  is  not  indicated, 
and  the  condition  should  be  treated  by  mildly  antiseptic  vaginal  douches 
every  two  or  four  hours  until  the  temi)erature  falls,  which  will  usually  occur 
within  twelve  or  twenty-four  hours.  If  the  symptoms  do  not  subside, 
the  treatment  must  be  more  energetic  and  thorough.  Abdominal  pain 
and  tenderness,  or  local  pain  referred  to  the  vagina  or  iliac  regions,  will 


174  PUERPERAL   DISEASES. 

soon  be  developed,  accompanied  by  more  marked  constitutional  disturb- 
ances. 

If  the  vagina  alone  is  involved,  douching  is  all  the  local  treatment  in- 
dicated, unless  it  becomes  dipththeritic,  in  which  case  cauterization  must 
be  resorted  to.  This  may  be  done  with  a  strong  solution  of  chloride  of 
zinc.  Afterward  continue  frequent  irrigation  with  a  2'j  per  cent,  solution 
of  carbolic  acid  or  creolin.  As  soon  as  fresh  patches  are  found  they  are 
cauterized.  Between  the  douches  an  iodoform  suppository  containing  5 
or  10  grains  should  be  introduced. 

■  When  the  uterus  is  involved  the  first  indication  is  to  see  that  it  is 
empty.  For  this  purpose  an  anaesthetic  is  administered,  the  fingers,  or 
whole  hand  if  necessary,  introduced,  and  the  organ  completely  emptied 
of  any  foreign  matter.  If  enough  dilatation  of  the  cervix  for  this  pro- 
cedure is  not  present,  a  dull  wire  curette  may  be  used.  Following  this 
an  intra-uterine  douche  is  given.  Carbolic  acid,  creolin,  or  bichloride  of 
mercur}'  may  be  used.  If  the  latter,  the  solution  should  not  be  stronger 
than  ]  :  8000,  and  should  be  followed  by  a  thorough  irrigation  with  ster- 
ilized water.  A  long  strip  of  iodoform  gauze  is  then  introduced  lightly 
into  the  cavity  of  the  uterus,  and  allowed  to  remain  until  the  next  douche 
is  given,  or  an  iodoform  suppository  may  be  used.  It  frequently  hap- 
pens that  another  intra-uterine  douche  is  not  necessary,  though  some- 
times douches  must  be  given  as  often  as  every  four  or  six  hours.  If  this 
be  the  case,  bichloride  should  not  be  used.  To  relieve  the  pain  and  in- 
flammation nothing  is  as  satisfactory  as  cold.  This  is  preferably  applied 
by  the  ice-coil  or  bag. 

In  case  a  cellulitis  is  present,  the  same  indications  for  treatment  exist 
as  above  described,  though  frequent  warm  vaginal  douches  must  be  given 
until  resolution  is  complete,  and  to  aid  this.  When  this  condition  as- 
sumes a  subacute  or  chronic  form  the  vaginal  vault  may  be  painted  with 
tincture  of  iodine  every  other  day.  If  an  abscess  forms,  it  must  be 
o]>ened.  For  a  peritonitis  the  uterus  shovdd  be  first  thoroughly  cleansed. 
Repeated  irrigations  are  not  indicated.  Cold  externally  and  opium  hypo- 
dermically  or  by  the  rectum  are  indicated,  as  in  a  peritonitis  occurring 
under  otlier  circumstances.  Phlebitis  calls  for  the  treatment  already 
described. 

The  nourishment  of  the  patient  is  often  very  difficult,  owing  to  the 
severe  vomiting.  Peptonized  milk,  beef  juice,  and  mutton  l)roth  may 
all  be  given.  Rectal  alimentation  may  Ijecome  necessary.  Brandy  or 
wliiskey  is  indicated  from  the  begimiing.  A  half  ounce  every  three  or 
i'our  hours  may  be  gradually  increased  as  the  circulation  demand.>5  it.  ^  In 
combination  with  tlie  alcohol,  digitalis,  strophanthus,  caffeine,  strychnine, 
carbonate  of  ammonium — in  fact,  any  of  the  cardiac  stimulants — may 
be  given.  Quinine  should  be  given  in  5-  or  10-grain  doses  every  four  or 
six  hours.  Morphine,  to  relieve  i^ain  and  vomiting  as  well  as  the  diar- 
rhoea, is  always  indicated.  It  may  be  given  hy))odernii(ally,  combined 
witli  atropine.     Mustard  pastes,  iced  carbonic-acid  water,  bismuth,  dilute 


PHLEGMASIA    ALBA    DOLENS.  175 

hydrocj^anic  acid,  creasote,  carbolic  acid,  may  all  be  tried  if  vomiting  is 
excessive. 

To  reduce  the  temperature  sponge-baths  of  cold  water,  alcohol,  and 
hot  water  equal  parts,  or  the  cold  pack,  may  be  used.. 

In  pyaemia  the  abscesses  must  be  opened,  drained,  and  treated  anti- 
septically  as  they  occur. 

PHLEGMASIA  ALBA  DOLENS. 

What  is  phlegmasia  alba  dolens?  and  when  does  it  usually  oc- 
cur? 

It  is  a  swelling  of  one  of  the  lower  extremities,  owing  to  the  formation 
of  a  clot  in  the  veins  of  the  limb,  or  of  the  pelvis,  and  this  is  an  inter- 
ference with  the  return  circulation,  it  usually  occurs  within  two  weeks 
after  confinement,  generally  not  before  the  end  of  the  first  week.  The 
affection  is  also  called  peripheral  venous  thrombosis,  crural  phlebitis, 
milk  leg,  etc. 

What  is  its  pathology? 

This  is  disputed.  Many  think  it  maybe  due  either  to  septic  infection 
oris  of  non-septic  origin.  In  the  former  case  it  is  believed  to  occur  with 
a  phlebitis,  or  if  it  occurs  without  infection  it  is  the  result  of  detachment 
of  portions  of  the  coagula  at  the  utero-placental  site.  It  occurs  more 
frequently  in  multiparas  and  after  abortions  or  severe  hemorrhages. 

Describe  the  symptoms. 

Tlie  first  symptom  is  an  uncomfortable  feehng  of  the  limb  or  pain, 
usually  referred  at  first  either  to  the  groin  or  popliteal  space,  Soon  it 
becomes  very  severe,  and  slight  pressure  over  any  of  the  venous  trunks 
produces  a  sharp  exacerbation  of  the  pain.  The  limb  now  begins  to 
swell,  the  enlargement  beginning  in  the  groin  and  extending  down- 
ward, or  in  the  calf  of  the  leg,  extending  upward.  The  skin  acquires  a 
tense,  white,  shining  appearance,  and  oftentimes  the  a  eins  may  be  felt 
as  hard,  cord-like  masses  under  the  fingers. 

Constitutional  symptoms  may  be  severe  or  only  slightly  developed. 
There  is  generally  a  feeling  of  malaise,  followed  by  chilly  sensations  and 
a  rise  of  temperature  to  101°-1()3°  F.  The  pulse  is  accelerated,  and  the 
patient  complains  of  headache,  anorexia,  thirst,  and  sleeplessness.  In 
the  mild  cases  the  above  are  but  slightly  developed,  if  at  all. 

What  are  the  prognosis  and  treatment? 

The  x^yognosis  is  usually  very  favorable.  The  acute  stage  lasts  but  a 
few  days  or  a  week,  when  the  pain  becomes  less  marked,  swelling  is  di- 
minished, and  by  the  end  of  four  or  five  weeks  recovery  is  complete. 
The  limb,  however,  rarely  regains  its  normal  size,  but  always  remains 
slightly  enlarged. 

Treatment. — Absolute  rest  and  slight  elevation  of  the  limb  constitute 
our  local  treatment.     The  leg  should  be  wrapped  with  cotton  from  the 


176  PUERPERAL    DISEASES. 

toes  to  the  hip  and  slightly  elevated.     If  pain  is  severe,  hot  wet  cloths 
may  be  placed  next  the  skin  and  cotton  over  these. 

General  treatment  in  the  way  of  nourishing  food  and  good  hygienic 
surroundings  must  be  observed.  Tonics  are  indicated  after  recovery. 
All  active  treatment  in  the  way  of  massage,  poultices,  bhsters,  elec- 
tricity, depletion,  etc.  is  contraindicated. 

INSANITY. 

When  may  insanity  appear  during  pregnancy  and  after  labor? 

(1)  It  may  begin  at  any  time  after  conception,  and  be  but  transient, 
or  it  may  continue  throughout  gestation  and  after  labor.  The  usual 
time  of  its  appearance  is  about  the  fourth  month.  This  is  called  the 
"  insanity  of  pregnane}'." 

(2)  The  so-called  puerperal  insanity  is  some  form  of  insanity  beginning 
during  the  puerperal  state.  It  usually  appears  within  a  month  after 
delivery. 

(3)  insanity  of  lactation,  which  may  occur  at  any  time  while  the 
woman  is  nursing. 

State  the  causes. 

Heredity ;  mental  impressions ;  debility,  exhaustion,  or  anaemia ; 
septic  infection  :  painful  and  prolonged  labors  ;  possibly  chloroform  during 
delivery;  and  many  nervous  disorders, — are  all  given  as  causcfi.  The 
many  accidents  and  disorders  associated  with  pregnancy  and  parturition, 
such  as  injuries,  mental  disturbances,  albuminuria,  eclampsia,  chorea, 
hemorrhages,  etc.,  may  all  be  determining  causes.  A  large  percentage 
of  cases  occur  in  primiparae. 

Describe  the  symptoms  of  the  three  varieties. 

That  occurring  during  jn-egnancy  usually  is  melanchoha.  It  may  be 
only  slightly  developed,  and  lasts  but  a  short  time,  in  which  case  it  often- 
times passes  unrecognized.  In  these  mild  cases  a  depression  of  spirits 
with  insomnia  will  be  the  only  thing  noticed,  and  generally  this  is  at- 
tributed to  grief,  fright,  or  some  other  exciting  cause. 

Other  cases  become  more  serious  from  the  beginning,  many  times  con- 
tinuing after  delivery  and  assuming  a  maniacal  tendency.  There  are 
marked  depression,  irritability,  sleeplessness,  and  apprehension,  usually 
of  the  approaching  confinement.  The  woman  becomes  sullen  and 
gloomy,  her  affections  change,  and  interest  in  all  matters  is  lost.  The 
appearance  is  just  as  in  melancholia  occurring  under  other  circumstances, 
and  there  is  often  a  marked  tendency  to  suicide. 

After  delivery  the  variety  met  with  is  most  often  of  the  maniacal  type. 
It  may  foll<nv  a  melancholia  of  i)regnancy  or  begin  acutely  with  no  i)re- 
monitory  symiitoms.  This  is  the  most  frecjuent  of  the  three  varieties. 
There  may  be  first  n(jticed  a  restlessness  or  feeling  of  dislike  toward  hus- 
band, child,  or  friends,  which  cannot  be  explained,  or  suddenly  an  acute 


INSANITY.  177 

mania  is  developed.  The  patient  becomes  noisy  and  talkative,  her  con- 
versation incoherent,  and  often  of  an  obscene  or  vulgar  character.  All 
sense  of  modest}'  and  decency  is  lost.  She  has  hallucinations  and  delu- 
sions, and  both  the  sight  and  hearing  may  become  disordered.  She 
refuses  food,  is  sleepless,  and  is  extremely  restless.  Sometimes  the  dis- 
ordered mind  dwells  on  religious  subjects,  or  the  suicidal  or  homicidal 
tendency  is  strongly  developed. 

The  physical  condition  becomes  poor.  There  are  digestive  disturb- 
ances, some  temperature,  a  rapid  pulse,  and  involuntary  evacuations  of 
urine  and  faeces.     Emaciation  is  progressive  and  rapid. 

During  lactation  the  melancholic  type  is  generally  seen,  and  most  fre- 
quently in  multipar£e  who  have  borne  children  in  ra])id  succession  and 
nursed  as  long  as  this  has  been  possible.  They,  as  a  rule,  are  anaemic, 
poorly  nourished — physical  wrecks. 

The  sj^mptoms  are  such  as  already  stated,  only  that  hallucinations  are 
often  present,  as  in  the  suicidal  tendency,  and  sudden  violent  outbreaks 
of  acute  mania  may  occur. 

Any  of  these  forms  may  result  in  complete  recovery  or  may  go  on  to 
dementia. 

A  sudden  transitory  mania  occurring  during  labor  is  occasionally  seen. 
It  seems  to  bear  some  relation  to  and  depend  upon  the  severe  pain.  It 
is  of  but  a  few  moments'  duration. 

What  can  you  say  of  the  prognosis  ? 

The  prognosis  is  generally  favorable,  at  any  rate  as  to  life.  Some  die 
from  either  personal  violence  or  exhaustion,  while  some  cases  become 
chronic  or  the  patients  are  hopelessly  demented.  That  occurring  during 
pregnancy  is,  as  a  rule,  not  cured  until  after  labor.  Mania,  as  would  be 
supposed,  does  not  last  as  long  as  melancholia. 

How  are  these  cases  to  be  treated? 

The  most  nourishing  and  easily  digested  food  must  be  given  at  fre- 
quent intervals,  that  the  general  condition  of  the  patient  maj'  be  im- 
proved. Peptonized  milk,  broths,  beef  juice,  eggs,  etc.  may  all  be 
given.  If  the  patient  refuses  to  take  food,  gavage  and  rectal  alimenta- 
tion may  be  resorted  to.  However,  this  will  usually  be  unnecessary  if 
skilled  nurses  are  obtained  or  people  accustomed  to  care  for  the  insane. 
Mild  laxatives  may  be  necessary  to  combat  a  tendency  toward  constipa- 
tion. Fresh  air,  good  hygienic  surroundings,  and  careful  nursing  must 
all  be  obtained. 

In  the  way  of  drugs,  both  stimulants,  when  indicated,  and  sedatives 
and  hypnotics  must  be  used.  Morphine,  hyoscine,  chloral,  bromides, 
and  sulphonal  may  all  be  carefully  administered.  The  first  two  are 
especialh"  desirable  when  mania  is  present.  During  convalescence  tonics 
in  the  form  of  iron,  quinine,  strychnine,  and  arsenic  should  be  admin- 
istered, combined  with  plenty  of  fresh  air  and  moderate  exercise.  Quiet 
^surroundings  and  cheerful  companions  are  very  desirable. 

12— Obs. 


178  PUERPERAL   DISEASES. 

It  may  in  the  beginning  seem  best  to  place  the  patient  in  an  asyhim, 
though  this  must  depend  considerably  upon  the  surroundings  and  cir- 
cumstances, as  well  as  the  wishes  of  her  family  and  relatives. 

AFFECTIONS  OF  THE   NIPPLES  AND  BREASTS. 

What  extent  of  injury  to  the  nipple  may  occur  during  lactation  ? 
There  may  be  a  single  erosion  on  the  surface  from  a  loss  of  the  epithe- 
lium, due  to  the  nursing  of  the  child,  or  this  may  become  deeper,  con- 
stituting superficial  fissure,  or  deep  fissures  may  occur.  These  are  of 
traumatic  origin.  Occasionally  specific  ulcers  are  found  in  this  location, 
either  from  the  bite  of  a  syphilitic  child  or  in  a  woman  suftering  from 
this  disease,  and  rarely  is  found  an  eczematous  condition  of  the  areola 
and  nipple. 

What  are  the  symptoms  and  treatment  of  sore  nipples  ? 

The  symptoms  are  few  if  unaccompanied  by  complicating  disease  of  the 
breast.  There  is  great  pain  when  the  child  nurses,  which  does  not  en- 
tirely disappear  during  the  intervals  between  nursing.  This  in  neurotic 
women  is  apt  to  cause  an  irritable  or  even  hj^sterical  condition.  There 
may  be  a  slight  rise  of  temperature. 

The  treatment  is  both  prophylactic  and  curative.  The  former  consists 
in  washing  the  nipples  several  times  daily  during  the  latter  months  of 
pregnancy  with  some  astringent  fluid,  that  the  epithelium  may  become 
hardened.  A  solution  of  tannic  acid,  the  glycerite  of  tannin,  dilute  alco- 
hol, brandy,  solution  of  alum,  etc.  have  all  been  used.  Small  nipples 
should  be  developed  by  drawing  them  out  and  rolling  them  between  the 
fingers  and  thumb. 

Many  drugs  are  used  to  cure  eroded  nippies.  A  solution  of  nitrate 
of  silver  (grrxl-^j)  is  one  of  the  best.  The  eroded  surface  or  fissure  is 
touched  with  this,  and  then  dusted  with  bismuth,  and,  unless  the  ero- 
sion be  slight,  the  child  should  not  be  allowed  to  nurse  for  twenty-four 
or  forty-eight  hours.  In  this  case  the  milk  must  be  removed  by  the 
brea.st-pump.  It  may  be  necessary  to  repeat  the  application  of  the  silver 
several  times.  Tannin  is  dusted  over  the  erosion  by  some,  and  the  nip- 
])le  carefully  covered.  If  the  child  is  allowed  to  nurse,  this  must  be 
washed  off  before,  and  reapplied  after,  nursing.  The  nipple- shield 
should  be  used  in  every  ca.se  where  the  child  is  allowed  to  nurse  a  sore 
nipple. 

Specific  ulcers  require  both  local  and  constitutional  treatment.  Eczema 
is  treated  as  when  found  elsewhere. 

What  varieties  of  mastitis  are  met  with  ? 

(1)  Superficial  or  subcutaneou.s,  in  which  the  inflammation  is  just  be- 
neath the  skin  or  areola.  (2)  Glandular,  where  the  gland  tissue  itself  is 
involved.  (3)  Subglandular,  where  the  connective  tissue  between  the 
pectoralis  major  and  the  mammary  gland  is  involved.    The  second  is  the 


AFFECTIONS   OF   THE    NIPPLES   AND   BREASTS.  179 

most  frequent  of  the  three  varieties.     All  may  end  in  resolution,  or  sup- 
puration may  occur,  with  a  resulting  abscess. 

What  are  the  causes  of  mastitis  and  mammary  abscesses  ? 

Uneven  pressure  over  the  gland  in  the  form  of  improperly  applied 
breast-binders,  tight  clothing,  corsets,  etc.  is,  in  combination  with  an  ac- 
tively secreting  gland,  the  most  frequent  cause.  Infection  through  a 
fissured  or  eroded  nipple,  traumatic  injury,  and  cold  are  less  frequent 
causes.  A  mastitis  not  treated,  or  one  in  which  treatment  is  begun  late 
in  the  disease,  almost  invariably  goes  on  to  the  formation  of  one  or  more 
abscesses. 

Describe  the  symptoms. 

The  disease  may  begin  insidiously  or  very  acutely.  In  the  former  case 
there  is  a  feehng  of  discomfort  in  some  portion  of  the  breast,  usually  near 
the  periphery,  and  upon  examination  a  circumscribed  area  of  a  hard, 
knotty  feel  is  discovered.  This  is  tender  on  pressure,  though  there  is 
no  heat  or  redness  of  the  skin.  By  supporting  the  breast  properly,  and 
perhaps  removing  the  milk  by  gentle  stroking  with  the  tips  of  the  first 
three  fingers  dipped  in  oil  and  in  a  direction  from  the  periphery  toward 
the  nipple,  the  condition  is  soon  relieved  and  no  symptoms  follow. 

If  it  goes  on  unrelieved,  the  pain  becomes  more  severe,  the  skin  red- 
dens, is  hot  to  the  feel ;  there  is  a  general  feeling  of  malaise,  with  head- 
ache, thirst,  and  some  temperature.  When  the  inflammation  begins 
acuteW  there  is  either  a  chill  or  chilly  sensation,  followed  by  a  rise  of 
temperature  to  102°  or  even  105°  F.  This  is  associated  with  headache, 
loss  of  appetite,  thirst,  and  a  rapid  pulse.  The  breast  is  painful,  tender, 
red,  hard,  and  swollen. 

If  the  inflammation  be  superficial,  there  is  marked  redness,  over  a  cir- 
cumscribed area  usually,  though  it  may  be  diffiise.  Pain  is  a  constant 
symptom ;  there  is  some  temperature  and  a  general  feeling  of  malaise. 
Resolution  now  occurs  or  an  abscess  forms.  If  the  former,  all  the  symp- 
toms gradually  disappear ;  if  the  latter,  some  point  soon  becomes  more 
prominent  and  fluctuation  is  obtained. 

In  the  glandular  variety,  which  is  the  most  frequent  and  occurs  gen- 
erally within  a  few  weeks  after  delivery,  there  are  the  constitutional 
symptoms  already  described.  An  area  of  hardness,  circumscribed,  is 
found,  most  frequently  just  beyond  or  at  the  border  of  the  areola.  This 
is  painful  and  very  tender  on  pressure.  At  first  the  skin  over  the  indu- 
rated area  is  normal,  but  it  soon  becomes  red  and  hot.  If  resolution 
does  not  occur,  there  is  a  bulging  over  this  area,  a  soft  spot  appears  in 
the  centre,  and  a  rapid  breaking  down  occurs.  Some  time,  often  three 
or  four  weeks,  elap.ses  before  the  abscess  has  made  its  way  to  the  sur- 
face. 

In  the  subglandular  variety  the  constitutional  symptoms  are  rapidly 
developed.  The  pain  is  deep-seated  and  of  a  tearing  character.  There 
is  no  induration  of  the  breast  nor  redness  of  the  skin,  but  the  whole 


180  PUERPERAL    DISEASES. 

gland  appears  swollen.  This  form  almost  invariably  goes  on  to  suppura- 
tion, the  abscess  making  its  waj^  to  the  surface  at  the  peripher}^  of  the 
gland. 

What  are  the  dangers  that  may  arise  from  abscesses  of  the 
breast  ? 

As  a  rule,  the  subcutaneous  variety  gives  no  trouble  unless  the  inflam- 
mation becomes  diifuse  and  assumes  an  erysipelatous  character.  In  the 
glandular  variety  one  abscess  may  follow  another  until  the  entire  breast 
is  destroyed.  Septic  infection  may  occur  with  any  form.  Carcinoma  or 
sarcoma  is  frequently  found  in  breasts  which  have  been  the  seat  of  in- 
flammatory conditions.  Cellulitis  may  occur.  Perforation  of  the  chest- 
wall,  with  resulting  pleurisy,  has  followed  the  subglandular  variety. 

How  should  a  mastitis  be  treated? 

If  the  breasts  are  properly  supported  for  two  or  three  weeks  following 
the  birth  of  the  child  by  a  well-applied  breast-binder,  and  if  eroded  nip- 
ples are  treated  as  soon  as  they  are  found,  few  cases  of  mastitis  will  arise. 

The  curatke  treatment  consists  in  rest,  support  of  the  inflamed  gland, 
and  the  local  application  of  cold.  The  patient,  if  not  already  in  bed, 
should  be  placed  there,  and  the  breast  supported  by  a  sling  passed  around 
the  neck  and  under  the  gland.  If  much  febrile  disturbance  is  present, 
the  diet  should  be  restricted  to  milk.  A  saline  cathartic  is  desirable,  or 
a  dose  of  calomel  followed  by  a  saline.  Quinine  in  5-grain  doses  ever\^ 
four  or  five  hours  should  be  given.  Cold  may  be  apj^lied  by  the  use  of 
the  ice-bag,  rubber  coil,  or  evaporating  lotions.  The  former  is  generally 
the  most  convenient  and  best.  If  the  nipples  are  not  badly  eroded,  and 
if  no  pus  is  present,  the  child  may  be  allowed  to  nurse ;  otherwise,  the 
milk  must  be  removed  by  gentle  stroking. 

When  all  hope  of  preventing  suppuration  is  passed,  this  may  be  hast- 
ened by  the  aj^plication  of  warm  flaxseed  poultices.  When  the  abscess 
is  formed  it  must  be  opened.  The  subcutaneous  variety  simply  requires 
a  moderate  incision,  evacuation  of  the  pus,  thorough  cleansing,  and  the 
ai)i)lication  of  an  antiseptic  dressing.  With  the  glandular  variety  we 
should  wait  f(jr  the  abscess  to  appear  near  the  surface.  Make  a  free 
oi)ening,  drain  the  cavity,  and  secure  free  exit  for  the  pus  by  the  intro- 
duction of  drainage-tubes.  Counter-openings  will  usually  be  necessary. 
The  incisions  in  both  the  above  should  be  made  in  a  direction  from  tlie 
nipi)le  toward  the  jieriphery,  as  there  is  less  gai)ing  and  the  resulting 
scar  is  smaller.  Make  the  incision  entirely  within  or  without  the  areola, 
as  the  i)igment  will  often  follow  the  line  of  incision.  The  subglandular 
variety  must  be  opened  where  it  points,  at  the  periphery.  The  incision 
should  be  free  and  parallel  to  the  circimiference  of  the  breast.  Use  a 
drainage-tube.  An  antiseptic  dressing  is  applied  and  changed  once  dail}'^, 
washing  out  the  cavities  and  shortening  the  tubes  with  each  dressing. 

Ether  may  be  administered  when  the  openings  are  made,  but  local 
anaesthesia  with  the  ether  spray,  cracked  ice  and  salt,  or  cocaine  will 


TFIE    INFANT.  181 

nsuall.v  be  effectual  in  preventing  pain.     Daring  convalescence  tonics  are 
indicated. 

State  the  method  of  drying  the  breasts  when  for  any  reason 
this  becomes  necessary. 

Hot-water  stupes  are  applied  to  both  for  half  an  hour  or  an  hour,  chang- 
ing them  every  few  minutes,  that  they  may  be  l^ept  hot.  Following  this, 
the  entire  gland  is  either  smeared  with  belladonna  ointment  or  covered  with 
a  clotli  soaked  in  a  weak  solution  of  atropine  and  liquid  vaseline  or  glycerin. 
Next,  over  the  entire  breasts,  extending  from  one  posterior  axillary  line 
to  the  other,  is  placed  a  thick  layer  of  non-absorbent  cotton  and  a  binder 
is  tightly  applied.  This  need  not  be  removed  for  ten  days,  but  should 
be  tightened  a  little  every  da}'  as  the  breasts  decrease  in  size.  The  bow- 
els are  to  be  kept  open  by  salines,  and  as  far  as  possible  all  fluids  re- 
stiicted  from  the  diet  for  a  few  daj's. 


CHAPTER   IX. 
THE   INFANT. 

RESUSCITATION  FROM   ASPHYXIA. 

What  is  asphyxia  neonatorum  ?  and  in  what  forms  does  it  occur  ? 

It  is  the  apparent  death  of  the  newborn  child.  Two  forms  are  seen 
— the  cyanotic  and  the  antemie.  In  the  former  the  face  and  lips  are 
swollen  and  of  a  livid  or  bluish  color ;  the  heart  beats  faintly  and  slowly ; 
the  child  generally  makes  feeble  efforts  at  respiration  at  infrequent  inter- 
vals, though  it  does  not  cry  out.  Slight  reflexes  may  be  present.  The 
prognosis  in  this  variety  is  good.  In  the  anemic  form  the  face  and 
body  are  very  pale  and  cold,  the  lips  and  conjunctivae  bloodless,  the 
muscles  limp  and  flaccid,  and  the  mouth  open.  There  is  no  cardiac 
action,  or  if  there  is  any  it  is  almost  impossible  to  hear  it  with  the 
stethoscope,  and  there  are  no  attempts  at  respiration. 

The  prognosis  in  these  cases  is  extremely  grave. 

What  methods  are  used  for  resuscitation? 

Many  times,  in  the  cyanotic  variety,  all  that  will  be  necessary  is  a  few 
sharp  slaps  on  the  buttocks,  chest,  or  back  either  with  the  hand  or  the 
wet  end  of  a  towel.  If  this  is  not  successful,  the  back  and  chest  should 
be  briskly  rubbed  with  alcohol  or  brandy  while  a  hot  bath  is  being  pre- 
pared. The  temperature  of  the  water  may  be  106°  to  110°  F.,  or  even 
a  little  hotter.  The  cord  is  now  ligated  some  few  inches  from  the  um- 
bilicus, and.  grasping  it  at  the  navel  between  the  thumb  and  fingers,  cut 
it  on  the  umbilical  side  of  the  ligature,  and  allow  two  or  three  drachms 
of  blood  to  escape.     This  often  relieves  the  congestion  and  respiration 


182  THE   INFANT. 

begins.  If  not,  place  the  infant,  after  ligating  the  cord,  in  the  bath, 
allowing  it  to  remain  but  a  few  seconds.  Taking  it  out,  let  the  buttocks 
or  back  rest  for  a  second  in  a  basin  of  ice  or  cold  water.  This  may  be 
repeated  three  or  four  times,  and  usually  with  gratifying  results. 

Insufflation  of  the  lungs  and  artificial  respiration  now  remain  to  be 
tried  if  all  the  other  methods  have  failed.  The  former  may  be  done  by 
introducing  a  catheter  into  the  trachea — which  is  not  an  easy  procedure 
— or  by  cutting  a  small  hole  in  a  piece  of  cloth,  placing  the  opening  over 
the  infant's  mouth,  applying  the  lips  to  this,  and  gently  blowing.  There 
are  a  number  of  methods  of  artificial  respiration. 

The  faradic  current  aj^plied  over  the  course  of  the  phrenic  nerves  will 
sometimes  excite  respiration,  and  this  may  be  tried  if  a  battery  is  at 
hand. 

In  the  anaemic  variety  do  not  allow  any  blood  to  escape  from  the  cord, 
but,  on  the  contrary,  do  not  ligate  it  until  the  pulsations  have  ceased, 
The  other  procedures  in  the  order  described  above  may  be  tried  in  this 
variety  just  as  in  the  cyanotic. 

Describe  the  methods  of  artificial  respiration. 

{])  Syh- ester's. — The  child  is  laid  upon  its  back  with  its  shoulders 
slightly  elevated.  The  physician,  standing  at  the  head,  grasps  the  arms 
at  the  elbows  and  alternately  raises  them  above  the  head  and  depresses 
them  against  the  sides  of  the  chest.  This  produces  inspiration  and  ex- 
piration. This  is  preferable  to  all  the  others,  as  less  exposure  of  the  in- 
i'ant  is  necessary.  While  being  performed  nearly  the  entire  body  may 
be  wrapped  in  a  warm  blanket. 

(2)  Schiltzes. — The  child  is  taken  in  both  hands  Avith  the  head  point- 
ing toward  the  operator.  The  fingers  lie  across  tlie  back  at  the  scajiulae, 
with  the  thumbs  against  the  sides  and  front  of  the  chest.  The  face  looks 
upward.  Lifting  it  from  the  bed  in  this  manner,  the  head  and  lower 
part  of  the  trunk  and  extremities  fall  backward.  The  diaphragm  is  de- 
pressed, and  the  traction  of  the  head  elongates  the  chest  wall  Inspira- 
tion results.  Then,  by  swinging  the  child  so  that  it  doubles  upon  itself, 
the  head  and  lower  extremities  fall  forward,  the  infant  rests  upon  the 
thumbs,  and  expiration  takes  place.  By  repeating  these  movements  an- 
other complete  respiration  is  produced. 

(3)  Direct  pressure  with  the  palms  of  the  hands  and  fingers  against 
the  sides  and  front  of  the  thorax. 

Many  other  methods  are  described,  but  the  above  are  those  generally 
used. 

What  signs  indicate  further  efforts  at  resuscitation  hopeless? 

An  absence  of  the  heart-sounds  for  a  minute  or  two;  no  response  to 
external  irritations ;  absence  of  all  reflexes. 

Until  all  methods  have  been  thoroughly  tried,  we  should  not  cease  our 
efforts  at  resuscitation,  as,  many  times,  twenty  minutes  or  a  half  liour  may 
elapse  before  any  indications  of  life  become  apparent. 


NURSING. — DISEASES   OF   THE    NEWBORN.  183 

How  long,  after  all  foetal  heart-sounds  have  disappeared  from  over 
the  abdomen,  there  is  still  a  possibility  of  reviving  the  infant  is  a  ques- 
tion difficult  to  decide.  If  they  have  been  ])reviously  distinct,  but  absent 
for  more  than  five  or  eight  minutes  before  birth,  there  is  little  hope  of  re- 
suscitation. 

NURSING-. 

How  frequently  should  the  infant  be  nursed?  and  when  may  it 
be  weaned? 

During  the  first  month  a  healthy  full-term  child  may  be  allowed  to 
nurse  nine  or  ten  times  during  each  twenty-four  hours.  This  may  be 
divided  something  after  this  fashion:  at  six,  eight,  ten,  and  twelve  in  the 
morning,  and  at  two,  four,  six,  and  eight  in  the  afternoon.  During  the 
night  it  may  require  one  or  two  nursings,  the  hours  depending  upon  when 
it  awakens.  It  should  never  remain  at  the  breast  longer  than  twenty 
minutes,  and  oftentimes  ten  or  fifteen  will  be  sufficient. 

After  the  first  month  the  intervals  between  the  feedings  should  be 
lengthened  to  two  and  a  half  hours,  and  by  the  end  of  the  second  month 
to  three,  with  perhaps  no  nursing  during  the  night — at  least  not  more 
than  one. 

At  the  end  of  seven  or  eight  months  five  nursings  a  day  are  all  that 
are  necessary. 

It  is  difficult  to  know  exactly  the  proper  time  for  weaning  the  infant 
from  the  breast,  but  in  the  vast  majority  of  cases  it  should  be  done  at 
the  end  of  the  twelfth  or  fourteenth  month.  It  may  be  gradually  ac- 
complished by  giving  the  child  some  suitable  food  three  or  four  months 
before  nursing  is  stopped  entirely. 

DISEASES  OF   THE  NEWBORN. 

Describe  spina  bifida. 

It  is  a  tumor  situated  over  some  portion  of  the  spine,  and  contains 
cerebro-spinal  fluid  and  the  meninges  of  the  cord.  It  is  caused  by  an 
absence  of  the  arches  of  one  or  more  of  the  vertebrae. 

Sipivptoms. — As  a  rule,  it  is  found  as  a  fluctuating  tumor  at  the  lower 
\iart  of  the  spine.  It  may  or  may  not  be  covered  by  skin.  On  causing 
ihe  child  to  cry  the  tumor  enlarges,  and  becomes  smaller  on  compressing 
it.  Pressure  may  be  followed  by  cerebral  symptoms.  Hydrocephalus 
is  often  associated  with  it. 

Prognosis. — Grave;  its  termination  is  usually  death,  preceded  by  an 
ulceration  of  the  sac,  rupture,  escape  of  the  fluid,  and  convulsions. 
Cases  occasionally  are  cured. 

Treatment. — If  .small  and  showing  no  tendency  to  increase  in  size, 
simply  protect  it  from  the  irritation  of  the  clothing.  If  large  or  increas- 
ing in  size,  surgical  interference  is  necessary.  The  sac  may  be  punctured 
it  one  side  of  the  median  line  to  prevent  injuring  the  cord,  and  part  of 


184  THE    INFANT. 

the  fluid  withdrawn.  Then  cover  with  a  soft  pad,  and  repeat  the  opera- 
tion at  intervals  of  a  few  da\'S  until  all  the  fluid  is  removed.  Iodine  is 
injected  into  the  sac  by  some.  It  is  usual  to  use  J  or  2  parts  of  iodine, 
arid  the  same  of  iodide  of  potassium,  to  20  or  30  parts  of  water.  Some 
of  the  fluid  is  withdrawn,  the  pedicle  comi)ressed,  so  that  the  iodine 
solution  does  not  enter  the  canal,  and  the  solution  slo^yly  injected.  After 
remaining  a  short  time  it  is  withdrawn.  The  injection  may  have  to  be 
repeated  several  times. 

Describe  congenital  cyanosis. 

It  generally  begins  a  few  hours  after  birth,  but  may  not  show  itself 
for  a  week  or  more,  and  consists  in  a  bluish  appearance  of  the  entire 
body. 

Causes. — ]\Iany  theories  as  to  its  etiology  have  been  advanced.  Most 
believe  it  to  be  due  to  a  malformation  of  the  heart  and  large  vessels  in 
its  vicinity  from  lack  of  development,  thus  preventing  the  flow  of  blood 
to  and  from  the  lungs. 

Sijmptoms.— The  skin  is  dusky  or  purplish  in  color,  and  more  so  after 
exercise.  At  rest  it  assumes  more  nearly  its  normal  hue;  generally 
most  marked  about  the  face  and  lips.  Disorders  of  digestion,  constipa- 
tion, or  diarrhoea  are  usually  present,  and  the  child  remains  small  and 
poorly  nourished.  The  bodily  temperature  is  almost  invariably  subnormal. 
The  heart's  action  is  usually  irregular,  and  becomes  very  frequent  on 
slight  exertion.  Palpitation  is  generally  i)resent.  Irregular  murmurs 
may  be  heard  over  the  heart.  The  respiration  is  increased  in  frequency. 
There  may  be  oedema  of  the  limbs. 

Prognom. — Not  good  ;  most  die  very  early. 

Treatment. — Rest  and  quiet,  good  hygienic  surroundings,  proper  cloth- 
ing, nutritious  and  easily  digested  food  are  of  most  importance.  ^  Coun- 
ter-irritation over  the  chest  in  the  way  of  mustard  pastes  or  brisk  rub- 
bing is  useful.  Brandy  or  digitalis  may  be  of  benefit.  Inhalations  of 
oxygen  sometimes  relieve  urgent  symptoms. 

How  would  you  treat  an  ophthalmia  or  purulent  conjunctivitis 
in  the  newborn  ? 

Two  or  three  drops  of  a  gr.  v  to  the  ounce  solution  of  nitrate  of  silver 
should  be  dropped  in  the  eye,  and  may  be  repeated  once  or  twice  daily 
for  several  days  if  the  affection  be  severe.  Thorough  and  frequent 
cleansing  of  th(!  inflamed  eye  with  a  strong  soliUioii  of  boracic  acid  or  a 
very  weak  solution  of  bichloride!  of  mercury  is  very  essential.  Every 
twenty  minutes  or  half  an  hour  is  not  too  freciuent.  Ice-cloths  should 
be  constantly  applied.  These  must  be  changed  often,  that  they  may  be 
kept  cold.  Active  and  thorough  treatment  begun  in  time  will  almost 
invariably  result  in  the  saviiit:  of  the  eyes. 

Is  mastitis  a  frequent  disease  of  the  newborn  ? 

It  occasionally  occurs.     The  glands,  one  or  both,  become  swollen,  red, 


DISEASES    OE    TPIE    NEWBORN.  185 

tender,  and  hot.  There  is  associated  with  the  local  sym])toms  some  tem- 
perature and  irritability  and  iretfulness  of  the  infant.  The  disease  usu- 
ally occurs  in  very  young  infants,  generally  within  the  first  two  or  three 
weeks  of  life. 

No  treatment,  more  than  covering  with  cotton  to  prevent  irritation  of 
the  clothing,  is  required.  The  child  should  never  be  manipulated, 
srjueezed,  or  rubbed.  If  an  abscess  forms — which  is  exceptional — it 
must  be  opened.  Use  very  weak  solutions  of  carbolic  acid  or  bichloride 
of  mercury,  as  children  are  extremely  susceptible  to  poisoning  by  these 
drugs. 

Describe   the  accidents  occurring  to  the  umbilicus  after  separa- 
tion of  the  cord. 

(1)  Heynorrhafj(\ — This  usually  takes  place  at  the  time  the  cord  be- 
comes detached — namely,  from  the  fifth  to  the  seventh  day — though  it 
may  occur  at  the  base  of  the  cord  any  time  after  birth.  The  most  fre- 
quent cause  is  the  hemorrhagic  diathesis  or  haemophilia.  This  diathesis 
may  be  due  to  syphilitic  taint. 

Symptom fi. — A  slight  jaimdice  in  many  cases  precedes  the  hemorrhage, 
which  occurs  as  an  oozing  from  the  umbilicus.  This  continues  until  the 
child  dies  from  exhaustion  on  account  of  the  loss  of  blood,  or  if  checked 
purpuric  spots  appear  over  the  body.  There  may  be  hemorrhages  from 
the  nose,  or  into  the  abdominal  cavity,  the  stomach,  or  the  intestines. 

The  prorjnosis  is  unfavorable.     Recoveries  are  rare. 

Treatment. — Styptics  may  be  tried :  of  these  the  liquor  ferri  subsul- 
phatis  is  best.  A  piece  of  cotton  saturated  with  the  solution  is  pressed 
against  the  bleeding  surface  and  held  there  for  a  few  minutes.  If  this 
does  not  succeed  in  stopping  the  hemorrhage,  two  needles  may  be  passed 
through  the  umbilicus  at  right  angles  and  a  silk  suture  wound  around 
each  in  the  form  of  the  figure  S.  These  must  be  removed  in  six  or 
eight  houis  and  an  aiitiseptic  dressing  applied.  Plaster  of  Paris  is  some- 
times used  in  this  way  :  A  thick  layer  is  allowed  to  harden  over  the  um- 
bilicus, and  then  held  in  place  by  the  binder.  Brandy  must  be  given  in 
small  doses  as  a  cardiac  stimulant.  P]ven  if  the  hemorrhage  is  checked 
at  the  umbilicus,  it  is  likely  to  appear  elsewhere,  so  tliat  any  treatment 
avails  little. 

(2)  Vegetations  at  the  umbilicus  frequently  appear  after  the  cord  has 
desiccated  and  dropped  off.  They  are  simply  exuberant  granulations, 
and  are  to  be  treated  as  such  by  rip])ing  them  off  or  touching  them 
with  nitrate  of  silver ;  or  they  may  be  tied  off.  Care  must  be  taken  to 
differentiate  this  condition  from  an  umbilical  hernia,  which  may  be 
readily  done  by  its  smaller  size,  appearance,  and  irreducibility. 

(3)  Umhih'cal  Hernia. — This  may  appear  within  the  first  few  weeks 
of  life,  but  usually  not  until  later. 

The  freatmient  consists  in  the  reduction  of  the  tumor,  and  tlie  applica- 
tion over  the  opening  of  a  moderate-sized  wooden  button,  held  in  place 
by  two  strips  of  adhesive  plaster  crossed  in  the  centre. 


186  THE    INFANT. 

What  is  icterus  neonatorum? 

It  is  a  yellow  discoloration  of  the  skin. 

Causes. — Duodenitis,  congenital  malformation  or  obliteration  of  the 
bile-ducts,  hereditary  syphilis,  and  changes  in  the  blood  not  well  under- 
stood. It  generally  appears  on  the  second  or  third  day,  and  disappears 
within  a  week  or  ten  days  in  the  vast  majority  of  cases. 

As  a  rule  no  treatment  is  required.  If  evidences  of  syphilis  are  pres- 
ent, this  must  be  treated,  and  inflammatory  conditions  of  the  duodenum — 
which  must  be  extremely  rare — require  treatment. 

What  are  the  causes  and  symptoms  of  tetanus  in  the  newborn  ? 

Bad  hj^gienic  surroundings  and  exposure  to  wet  or  cold  are  the  frequent 
causes.  The  disease  generally  begins  during  the  first  week  of  life,  and 
may  be,  usually  is,  preceded  by  no  premonitory  symptoms.  The  first  thing 
noticed  is  an  inability  to  nurse,  and  upon  examination  a  rigidity  of  the 
muscles  of  the  jaw  is  found.  This  extends  over  the  body  until  all  or 
nearly  all  the  voluntary  muscles  become  involved.  Opisthotonos  is 
generally  developed,  and  respiration  so  interfered  with  that  cyanosis  re- 
sults. There  are  periods  when  some  relaxation  occurs  and  the  symp- 
toms improve.  Deglutition  is  so  painful  and  difficult  that,  even  though 
food  is  put  into  the  mouth,  the  infant  cannot  swallow.  Exhaustion  and 
emaciation  progress  rapidly,  and  death  follows  in  a  sliort  time. 

Is  there  any  treatment  for  the  disease? 

Many  remedies  have  been  used,  but  none  with  any  great  success. 
Chloral,  the  bromides,  or  opium  for  controlling  the  spasms  may  all  be 
tried.  They  may  be  given  by  the  rectum  if  the  child  cannot  swallow. 
Brandy  to  combat  the  exhaustion  is  indicated  from  the  beginning.  This 
is  an  extremely  rare  disease  now,  though  some  years  ago  it  was  very  com- 
mon. 

How  may  septic  infection  enter  the  child's  system? 

Generally  through  the  umbilicus  from  inflammations  and  ulcerations 
here,  or  through  the  umbilical  vein,  though  cases  are  recorded  where  the 
infections  must  have  occurred  through  sores  and  injuries  over  other  por- 
tions of  the  body. 


INDEX. 


A. 

Abdominal  palpation,  82 

pregnancy,  59,  60 
Abortion,  66 

induction  of,  145.  146 
methods,  147,  14S 
Abscess  of  breast,  178,  179 
After-pains,  94 
Albuminuria.  52 

course,  treatment,  and  symptom; 
Allantois,  29 
Amnion,  30 

hydramnion,  63 
Antesthesia,  S9 
Analgesia,  89 
Artificial  respiration,  182 
Asphyxia  neonatorum,  181 

B. 

Ballotteraent,  41 
Breasts,  22,  17S 

abscess  of.  178,  179 

drying,  181 

c. 

Csesarean  section,  164,  165 

modifications  of,  167 
Caput  succedaneum,  82 
Care  of  infant,  96 
Chloral,  90 
Chloroform,  90 
Chorion,  .30 

diseases  of,  63 

villi,  .30 
Complex  presentations,  113 
Conception,  26 
Congenital  cyanosis,  184 
Conjunctivitis,  184 
Contracted    pelvis.      See    Pelris, 
traded. 

Obs. 


j  Cord,  diseases  of,  63 

I  Corpus  luteum,  25 
I  Craniotomy,  161,  163 
instruments,  161,  162 
Cyanosis,  congenital,  184 

D. 

Decapitating,  163 
Decidua,  diseases  of,  61 
Diameters  of  fcetal  skull,  33 
Ditficult  breech  presentations,  107, 108 
Displacements  of  the  uterus,  51 

varieties  of,  51,  .52 
Dystocia,  fcetal,  133 

E. 

Eclampsia,  54 
symptoms,  55 
treatmeiit,  55,  .56 
Embryotomy  instruments,  161 
basiotribe,  162 
cephalotribe,  162 
cranioclast,  162 
crotchet,  162 
perforator,  161 
!  Encephalocele,  134 
Epiblast,  28 
Episiotomv,  93 
Ether,  91  ' 
Evisceration,  164 

F. 

False  pains,  75 
Fecundation,  26 
Fillet.  161 
Fcetal  dvstocia,  133 

head,  32 

heart-sounds,  41 
Foetus,  anomalies  of,  132 

187 


188 


INDEX. 


Foetus,  attitude  of,  in  utero,  35 
circulation  of,  34 

changes  at  birth,  35 
death  of,  in  utero,  45 
description  of,  31 
diseases  of,  61,  64 
extraction  of,  155 
moles,  65 
false,  65 
true,  65 
nutrition  of,  in  utero,  34 
respiration  of,  in  utero,  34 
secretions  of,  in  utero,  34 
Forceps,  155 
application  of,  156 
in  breech  cases,  160 
in  face  cases,  160 
indications  for,  156 
operations,  dangers  of,  161 
high,  156,  160 
low,  156 
powers  of,  155 
removal  of,  159 
Funic  soufHe,  42 
Funis,  prolapse  of,  114 
diagnosis,  115 
treatment,  115 

G. 

Generation,  organs  of,  18,  19 
Graafian  follicles,  23,  24 

H. 

Hsemorrhages  during  labor,  135 
post-partum,  135 

causes,  136 

symptoms,  136 

treatment,  137 
Hour-glass  contraction  of  the  uterus, 

119 
Hydramnion,  63 
Hvdrocei)halus,  134 
Hypoblast,  28 

I. 

Icterus  neonatorum,  186 
Infant,  care  of,  96 
Infection,  jjuerperal,  169 
Infusion,  169 
Insanity,  176 
causes  of,  176 


Insanity,  prognosis,  177 
symptoms  of,  176 
treatment,  177 
varieties  of,  176 

L. 

Labor,  74 

accidents  during,  143-145 

causes  and  treatment,  119  123 

definition,  74 

duration,  77 

false  pains,  75 

first  stage,  76 

induction  of,  methods,  147,  148 

management,  84-89 

obstructed,  119 

precipitate,  118 

protracted,  116 

management  of,  117,  118 

second  stage,  76 

stages,  75 

symptoms,  75 

third  stage,  77 

uterine  contractions,  74 
Labors,  unnatural,  97 
Laparo-elytrotomy,  167 

M. 

Malformations  of  the  pelvis,  123-129 
Mammary  abscess,  178,  179 
Mastitis, 'l78. 184 

causes,  179 

symptoms,  179 

treatment,  180 

varieties,  178 
Mechanism  in  vertex  cases,  78-81 
Menopause,  24 
Menstruation,  24,  25 
Mesoblast,  28 
Miscarriage,  66 

diagnosis,  67,  68 

symptoms,  67 
Missed  labor,  60 
Moles,  65 
Monstrosities,  134 

N. 

Naegele's  pelvis,  128 
Nipples,  178 

injuries  to,  178 

soreness  of,  178 


INDEX. 


189 


Nubility,  24 
Nursing,  183 


o. 


Ophthalmia,  184 
Osteomalacic  pelvis,  127 
Ovulation,  24,  25 
Ovum,  development  of,  28 

diseases  of,  61 

impregnated,  27 

P. 

Pelvis,  20 
alterations  of,  in  pregnancy,  21 
contracted,  diagnosis,  129 
effects  on  pregnancy,  130 
mechanism,  130 
prognosis,  130 
treatment,  131 
malformations  of,  123-129 
planes  of,  21 
Perineum,  lacerations  of,  91 

management,  92 
Phenomena  of  pregnancy,  36 
changes  in  the  pelvis,  36-39 
changes  in  the  soft  parts,  36-39 
Phlegmasia  alba  dolens,  175 
Placenta,  30 
diseases  of,  62 
'previa,  71 
causes,  72 
diagnosis,  73 
prognosis,  72 
symptoms,  72 
treatment,  73 
Plural  births,  132 
Position,  78 

mechanism,  vertex  cases,  78-81 
Post-partum  haemorrhage,  135 
Pregnancy,  differential  diagnosis,  44, 
45 
diseases  occurring  with,  56,  57 
disorders  of,  46-50 
duration,  43 
extra-uterine,  57 

varieties  of,  57-59 
hgemorrhages  in,  69 
causes,  70 
treatment,  71 
hygiene  of,  46 
method  of  examination,  43 
multiple,  60 


Pregnancy,  phenomena  of,  36 

symptoms  and  diagnosis,  39-43 
Premature  labor,  69 

induction  of,  146 
Presentation,  78 

breech,  diagnosis,  83 
vertex,  diagnosis,  83,  84 
Presentations,  complex,  113 
difficult  breech,  107,  108 
varieties  of.     See  Uiutatural  laborft. 
Prolapse  of  the  funis,  114 
Ptyalism,  49 
Puerperal  infection,  169 
occurrence,  170 
poison  of,  170 
prognosis,  173 
symptoms,  171,  172 
treatment,  173,  174 
varieties  of,  170,  171 
state,  93-96 
thrombosis,  144 


Quickening,  41 


Q. 


R. 


Eachitic  pelvds.  126 
Eespiration,  artificial,  182 

S. 

Septic  infection,  entrance  into  system, 

186 
Sore  nipples,  178 
Spina  bifida,  183 
Spondylolisthesis,  129 
Spondj'lozemia,  129 
Spontaneous  evolution.  111 

version.  111 
Sterility,  26 

female,  27 

male,  26 
Sudden  death,  144 
Superfecundation,  61 
Superfoetation,  61 
Symphysiotomy,  168 

T. 

Tetanus,  186 

Thrombosis,  puerperal,  144 
Transfusion,  168 
Tubal  pregnancy,  58 


190 


INDEX. 


u. 

Umbilical  cord,  31 

vesicle,  28 
Umbilicus,  accidents  to,  185 
Unnatural  labors,  97 

face  presentations,  97-100 
pelvic  presentations,  101-104,  107 
diagnosis,  104,  105 
Tuanagement,  105,  106 
persistent  occ.-post.  positions,  97 
trunk  i)resentations,  109-113 
Uterine  contractions,  40,  74 

souffle,  42 
Uterus,  displacements  of,  51 
hour-glass  contraction  of,  119 
inversion  of,  139 


Uterus,  inversion  of,  diagnosis,  140 
treatment,  140 
rupture  of,  141 
causes,  141 
diagnosis,  142 
symptoms,  142 
treatment,  142 

V. 

Viability,  146 
Vectis,  i61 
Vernix  caseosa,  32 
Version,  148 

dangers,  155 

methods,  149-154 

varieties,  14b 


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HISTOLOGY.     Klein,  p.  17  ;   Schafer's,  25  ;    Dunham,  8  ;  Nichols  & 

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SURGERY— OPERATIVE.     Stimson,  p.  27  ;  Smith,  26  ;  Treves,  29. 

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LARYNGOLOGY  and  RHINOLOGY.  Coakley,  p.  6  ; 

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fair,  23  ;  King,  17  ;  Jewett,  17  ;  Evans,  9. 

PEDIATRICS.    Smith,  p  26  ;  Thomson,  29  ;  Williams,  31  ;  Tuttle,  30. 

HYGIENE.     Egbert,  p.  9  ;  Richardson,  24  ;  Coates,  6. 

MEDICAL  JURISPRUDENCE.     Taylor,  p.  28. 

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been  said  and  done  in  surgery,  as  a    It  is   the   best  single   text-book   of 

succinct  and  logical  statement  of  the  ;  surgery  that  we  have  yet  seen  in  this 

principles  of  the  subject,  as  a  model    country. — New  York  Fost-Graduate. 

A  SYSTEM  OF  PRACTICAL  3IEDICINE  BY  AJMERICAN 
AUTHORS.  Edited  by  William  Pepper,  M.  D.,  LL.  D.  In  five 
large  octavo  volumes,  containing  5573  pages  and  198  illustrations.  Price 
per  volume,  cloth,  $5 ;  leather  $6  ;  half  Russia,  $7.  Sold  by  subscrip- 
tion only.     Prospectus  free  on  application  to  the  Publishers. 

ATTFIELD  (JOHN).     CHEMISTRY ;  GENERAL,  MEDICAL  AND 

PHARMACEUTICAL.     New  (UJth)  edition,  specially  revised  by  the 

Author  for  America.     In  one  handsome  12mo.  volume  of  784  pages, 

with  88  illustrations.     Cloth,  $2.50,  net. 

It  is  replete  with  the  latest  inform-    been  adopted,  bringing  the  work  into 

ation,  and  considers  the  chemistry  of   close  touch  with  the  latest    United 

every  substance  recognized  officially    States  Pharmacopoeia,  of  wliich  it  is 

or  in  general  practice.     The  modern    a  worthy  companion. — The  Pittsburg 

scientific  chemical  nomenclature  has    lledical  Review. 

BALLENGER  (W.  L.)  AND  WIPPERN  (A.  G.).  Shorth/.  A 
POCKET  TEXT-BOOK  (^F  DISEASES  OF  THE  EYE,  EAR, 
NOSE  AND  THROAT.  In  one  handsome  12mo.  volume  of  about 
400  pages,  with  many  illustrations.  7>m\s  Scries  of  Pocket  Text-books, 
edited'by  Uerx  !>.  Gallai'DET,  M.  D.    See  p.  18. 

BARNES  (ROBERT  AND  FANCOURT).  A  SYSTEM  OF  OB- 
STETRIC MEDICINE  AND  SURGERY.  Octavo,  872  pages,  with 
231  illus.     Cloth,  $5  ;  leather,  $6. 


4       Lea  Beothers  &  Co.,  Philadelphia  and  New  Yobk. 

BACON  (GORHAM).    ON  THE  EAR.    One  12mo.  volume,  400  pages, 
109  engravings  and  a  colored  plate.     Cloth,  net,  $2.00.     Just  ready. 
It  is  thehest  manual  upon  otology,    dents  of  medicine — Cleveland  Jour- 
An  intensely  practical  book  for  stu-  i  trial  of  Medicine. 

BARTHOL.OW  (ROBERTS).  CHOLERA;  ITS  CAUSATION,  PRE- 
VENTION AND  TREATMENT.  In  one  12mo.  volume  of  127  pages, 
with  9  illustrations.     Cloth,  $1.25. 

BARTHOLOW  (ROBERTS).  MEDICAL  ELECTRICITY.  A 
PRACTICAL  TREATISE  ON  THE  APPLICATIONS  OF  ELEC- 
TRICITY TO  MEDICINE  AND  SURGERY.  Third  edition.  In 
one  octavo  volume  of  308  pages,  with  110  illustrations. 

BELL  (F.  JEFFREY).  COMPARATIVE  ANATOMY  AND  PHYS- 
IOLOGY. In  one  12mo.  volume  of  561  pages,  with  229  engravings. 
Cloth,  $2.     See  Students'  Series  of  Manuals,  page  27. 

BILLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY. 

Including  in  one  alphabet  English,  French,  German,  Italian  and 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
In  two  very  handsome  imperial  octavo  volumes  containing  157-4 
pages  and  two  colored  plates.  Per  volume,  cloth,  $6 ;  leather,  $7 ; 
half  Morocco,  $8.50.  For  sale  by  subscription  only.  Specimen  pages 
on  application  to  the  publishers. 

BLACK  (D.  CAMPBELL).      THE    URINE    IN    HEALTH    AND 
DISEASE,  AND  URINARY  ANALYSIS,  PHYSIOLOGICALLY 
AND  PATHOLOGICALLY  CONSIDERED.     In  one  12mo.  volume 
of  256  pages,  with  73  engravings.     Cloth,  $2.75. 
A  concise,  yet  complete  manual,  |      Concise,    practical,  clinical,   well 


illustrated  and  well  printed. — Mary- 
land Medical  Journal. 


treating  of  the  subject  from  a  prac- 
tical and  clinical  standpoint. — The 
Ohio  Medical  Jonrnal. 

BLOXAM   (C.  L.).     CHEMISTRY,  INORGANIC  AND  ORGANIC. 

With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
Cloth,  $2  ;  leather,  $3. 

BROCKWAY  (F.  J.).  A  POCKET  TEXT-r>OOK  OF  ANATOMY. 
In  one  handsome  12mo.  volume  of  about  400  pages,  with  many  illus- 
trations. Shortly.  Lea's  Scries  of  Foe  kit  Text-books,  edited  by  Bern 
15.  Gallaudet,  M.  D.     See  page' 18. 

BRUCE  (J.  MITCHELL).  MATERIA  MEDICA  AND  THERA- 
PEUTICS. New  (6th)  edition.  In  one  12mo.  volume  of  600  pages. 
Just  ready.  Cloth,  $1.50,  net.  See  Student's  Series  of  Mamuilt, 
page,  27. 

PRINCIPLES  OF  TREATMENT.  In  one  octavo  volume.  Pre- 
paring. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo  vol. 
of  1040  pages,  with  727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

BURCHARD  (HENRY  H.).  DENTAL  PATHOLOGY  AND  THER- 
APEUTICS. Handsome  octavo,  575  pages,  with  400  illustrations. 
Just  ready.    Cloth,  net,  $5.C0;  leather,  net,  $6.00. 


Lea  Beothebs  &  Co.,  Philadelphia  and  New  Yobk.       5 

BURNETT  (CHARLES  H.j.  THE  EAR :  ITS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  Second  edition.  In  one  8vo.  volume  of 
580  pa^es,  with  107  illustrations.     Cloth,  $4;  leather,  $5. 

CARTER  (R.  BRUDENELL)  AND  FROST  ( W.  ADAMS).  OPH- 
THALMIC SUP.GEKY.  In  one  pocket-size  12rno.  volume  of  559 
pages,  with  91  engravings  and  one  plate.  Cloth,  $2.25.  See  Series  of 
Clinical  Manuals,  page  25. 

CASPARI   (CHARLES   JR.).  A  TREATISE  ON   PHARMACY. 

For  Students  and  Pharmacists.  In  one  handsome  octavo  volume  of 

680  pages,  with  288  illustrations.  Cloth,  $4.50. 

The  author's   duties  as   Professor  student  who  cannot  understand  must 

of  Theory  and  Practice  of  Pharmacy  be  dull  indeed.    The  book  is  full  of 

in  the  Maryland  College  of  Phar-  new,  clean,  sharp  illustrations, which 

macy,  and  his  contact  with  students  tell  the  story  frequently  at  a  glance, 

made    him    aware    of   their    exact  The  index  is  full  and  accurate. — 

wants  in  the   matter  of  a  manual.  National  Druggist. 
His    work    is   admirable,   and  the  i 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSI- 
OLOGY. New  (2d)  edition.  In  one  octavo  volume  of  921  pages, 
with  595  illustrations.     Just  ready.     Cloth,  $4.25  ;  leather,  $5.25,  net. 


In  every  respect  the  work  fulfils 
its  promise,  whether  as  a  complete 
treatise  for  the  student  or  as  an  ad- 


mirable work  of  reference  for  the 
physician. — North  Carolina  Medical 
Journal. 


CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE   (W.  -WATSON).    THE    TREATMENT    OF    WOUNDS, 

ULCERS  AND  ABSCESSES.     In  one  12mo.  volume  of  207  pages. 
Cloth,  $1.25. 

One    will    be    surprised     at    the  need  at  any  moment.     The  sections 

amount  of  practical  and  useful  in-  devoted  to  ulcers  and  abscesses  are 

formation  it  contains;  information  indispensable   to  any  physician. — 

that  the    practitioner  is    likely  to  The  Charlotte  Medical  Journal. 

CHEYNE  (W.  W.)  AND  BURGHARD  (F.  F.)  SURGICAL 
TREATMENT.  In  six  octavo  volumes,  illustrated.  Volume  1,  299 
pages  and  QQ  engravings,  just  ready.     Cloth,  $3.00  net. 

CLARKE  (W.  B.)  AND  LOCKTVOOD  (C.  B.).  THE  DISSECTOR'S 
MANUAL.  In  one  12mo.  volume  of  396  pages,  with  49  engravings. 
Cloth,  $1.50.     See  Students'  Series  of  Manuals,  x^age  27. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY.     In  one  12mo.  vol.  of  178  pages.    Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  25. 

CLOUSTON  (THOMAS  S.).    CLINICAL  LECTURES  ON  MENTAL 

DISEASES.     New  (5th)  edition.     In  one  octavo  volume  of  750  pages, 
with  19  colored  plates.     Cloth,  $4.25,  net.     Junt  ready. 
^^"Folsom's  Abstract  of  Laws  of  JJ.  S.  on  Custody  of  Insane,  octavo, 
$1.50,  is  sold  in   conjunction  with  Clouston  on  Mental  Diseases  for 
$5.00,  net,  for  the  two  works. 


6      Lea  Broth EBfl  &  Co.,  Philadelphia,  and  New  Yoek. 

CLOWES  (FRANK).  AN  ELEMENTARY  TREATISE  ON  PRACTI- 
CAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS. From  the  fourth  English  edition.  In  one  handsome  12mo. 
volume  of  387  pages,  with  55  engravings.     Cloth,  $2.50. 

COAIiXiEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  NOSE,  THROAT,  NASO- 
PHARYNX AND  TRACHEA.  In  one  12mo.  volume  of  about  400 
pages,  fully  illustrated.    Preparing, 

COATES  (W.  E.,  JR.).  A  POCKET  TEXT-BOOK  OF  BACTE- 
RIOLOGY AND  HYGIENE.  In  one  handsome  12mo.  volume  of 
altout  ?50  pages,  with  many  illustrations.  Shortbj.  Lea's  Scries  of 
Pocket  l\'.vt-books,  edited  by  Bern  B.  Gallaudet,  M.  D.  See 
page  18. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol. 
of  829  pages,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).    A  MANUAL  OF  DENTAL  SURGERY 

AND  PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
handsome  octavo' vol.  of  412  pages,  with  331  engravings.    Cloth,  $3.25. 

COLLINS  (C.  P.).  A  POCKET  TEXT-BOOK  OF  MEDICAL 
DIAGNOSIS.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Shortly.  L^t's  Series  of  Pocket  Text-books, 
edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  18. 

COLLINS  (H.  D.)  AND  ROCKWELL  (W.  H.).  A  POCKET 
TEXT-BOOK  OF  PHYSIOLOGY.  In  one  handsome  12mo.  volume 
of  about  300  pages,  with  many  illustrations.  In  press.  Lea's  Series  of 
Pocket  Text-books,  edited  by  Bern  B.  Gallaudet,  M.  D.  See  page  18. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25 ;  leather,  $6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.  Translated,  with  Notes  and  Additions,  by 
J.  Henry  C.  Simes,  M.D.  and  J.  William  White,  M.D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  WOMEN.  In  one  handsome  12mo.  volume  of  about  350  pages, 
witli  many  illustrations.  Sliortly.  Left's  Series  of  Pocket  Te.vt-books, 
edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  18. 

CROOK    (JAMES      K.)    ON    MINERAL     WATERS     OF    THE 

UNITED  STATES.   Octavo,  575  pages.   Just  ready.   Cloth,  $3.50, 9? c^ 

CULBRETH  (DAVID  31.  R.).  MATERIA  MEDIC  A  AND  PHAR- 
MACOLOGY. In  one  handsome  octavo  volume  of  812  pages,  with 
445  illustrations.     Cloth,  $4.75. 

CUSHNY    (ARTHUR   R.).    TEXT-BOOK  OF  PHARMACOLOGY. 

Handsome  8vo.,  728  pages,  with  47  illus.  Just  ready.  Cloth,  $3.76,  net. 


Lea  Beothees  &  C!o.,  Philadelphia  and  New  Yoek.       7 

DALTON  (JOHN  C).   A  TREATISE  ON  HUMAN  PHYSIOLOGY. 

Seventh  edition.     Octavo,   722  pages,  with   252  engravings.     Cloth, 
$0 ;  leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.   In 


one  handsome  12mo.  volume  of  293  pages.     Cloth,  $2. 

DAVENPORT  (F.  H.).      DISEASES  OF  WOMEN.      A  Manual  ot 

Gynecology.  For  the  use  of  Students  and  Practitioners.  New 
(3d)  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  150 
illustrations.  '  Cloth,  $1.75,  net.     Just  ready. 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
STUDENTS  AND  PRACTITIONERS.  In  one  very  handsome 
octavo  volume  of  5-16  pages,  with  217  engravings  and  30  full-page 
plates  in  colors  and  monochrome.    Cloth,  $5 ;  leather,  $6. 

From  a  practical  standpoint  the  ]  thoroughly  scientific  and  brilliant 
work  is  all  that  could  be  desired.  A    treatise  on  obstetrics. —J/ecZ.  News. 

DAVIS  (F.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo 
volume  of  700  pages,  with  300  engravings.     Cloth,  $4. 

DENNIS  (FREDERIC  S.)  AND  BILLINGS  (JOHN  S.).  A  SYS- 
TEM OF  SURGERY.  In  contributions  by  American  Authors. 
Complete  work  in  four  very  handsome  octavo  volumes,  containing 
3652  pages,  with  1585  engravings  and  45  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cloth,  $6.00;  leather,  $7.00;  half 
Morocco,  gilt  back  and  top,  $8.50.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  publishers. 

It  is  worthy  of  the  position  which  [  American  surgery  and  is  thoroughly 
surgery  has  attained  in  the  great    practical. — Annals  of  Surgery. 
Republic  whence    it  comes.  —  The  '      No  work  in  English  can  be  con- 
London  Lancet.  \  sidered  as  the  rival  of  this. — The 

It  may  be  fairly  said  to  represent  American  Journal  of  the  3Iedical 
the    most     advanced    condition    of  i  Sciences. 

DERCU3I  (FRANCIS  X.,  EDITOR).  A  TEXT-BOOK  ON 
NERVOUS  DISEASES.  By  American  Authors.  In  one  handsome 
octavo  volume  of  1054  pages,  with  341  engravings  and  7  colored 
plates.     Cloth,  $6.00  ;  leather,  $7.00.    Net. 

Representing  the  actual  status  of  <  The  work  is  representative  of  the 
our  knowledge  of  its  subjects,  and  best  methods  of  teaching,  as  devel- 
the  latest  and  most  fully  up-to-date  oped  in  the  leading  medical  colleges 
of  any  of  its  class. — Jour,  of  Amer-  \  of  this  country. — Alienist  and  Neu- 
icon  Med.  Association.  rologist. 

The  most  thoroughly  up-to-date        The  best  text-book  in  any  Ian- 
treatise  that  we  have  on  this  subject,    guage. — The  Medical  Fortnightly. 
— American  Journal  of  Insanity.       i 

DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS. 
Their  Classification,  History,  Symptoms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  ])ages,  46  engravings,  and  9  full-page 
plates  in  colors.     Limited  edition,  de  luxe  binding,  $4.    Net. 


8       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

DRAPER  (JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  A  new  American,  from  the  twelfth  London 
edition,  edited  by  Stanley  Boyd,  F.  R.  C.  S.  In  one  large  octavo 
volume  of  965  pages,  with  373  engravings.     Cloth,  $4 ;  leather,  $5. 

DUANE  (AIjEXANDER).  THE  STUDENT'S  DICTIONARY  OF 
MEDICINE  AND  THE  ALLIED  SCIENCES.  New  edition.  Com- 
prising  the  Pronunciation,  Derivation  and  Full  Explanation  of  Medi- 
cal Terms,  with  much  Collateral  Descriptive  Matter,  Numerous  Tables, 
etc.  Square  octavo  of  658  pages.  Cloth,  $3.00 ;  half  leather,  $3.25 ; 
full  sheep,  $3.75.    Thumb-letter  Index,  50  cents  extra. 

DUDLEY  (E.  C).  THE  PRINCIPLES  AND  PRACTICE  OF 
GYNECOLOGY.  Handsome  octavo  of  652  pages,  with  422  illustra- 
tions in  black  and  colors.  Cloth,  $5.00,  net ;  leather,  $6.00,  net.  Just 
r*ady. 


tice  of  modern  gynecology. — Liter- 
national  Medical  3Iagazinc. 


The  book  can  be  safely  recom- 
mended as  a  complete  and  reliable 
exposition  of  the  principles  and  prac- 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE 
DISEASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.     Cloth,  $1.50. 

DUNGLiISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistiy,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  RoBLEY  DUNGLISON,  M.  D.,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  Edited 
by  Richard  J.  Dunglison,  A.  M.,  M.  D.  Twenty-first  edition,  thor- 
oughly revised  and  greatly  enlarged  and  improved,  with  the  Pronuncia- 
tion, Accentuation  and  Derivation  of  the  Terms.  With  Appendix. 
In  one  magnificent  imperial  octavo  volume  of  1225  pages.  Cloth,  $7  ; 
leather,  $8.    Thumb-letter  Index  for  quick  use,  75  cents  extra. 

The  most  satisfactory  and  authori-  scarcely  be  measured. — 3Ied.  Record. 

tative  guide  to  the  derivation,  defini-  Pronunciation  is  indicated  by  the 

tion  and  pronunciation  of  medical  phonetic  system.  The  definitions  are 

terms.— TAeCAaWo^ Seized.  Jour/iaZ.  unusually  clear  and  concise.    The 


book  is  wholly   satisfactory. —  Uni- 
versity 3Iedical  3Iagazine. 


Covering  the  entire  field  of  medi- 
cine,   surgery    and    the     collateral 
sciences,  its  range  of  usefulness  can 
DUNHAM  (EDWARD    K.).       MORBID    AND     NORMAL     HIS- 
TOLOGY.    Octavo,  450  page8,with  363  illustrations.  Cloth,  $3.25,  net. 
Just  ready. 
The  best  one- volume  text  or  refer- 1  of  published  in  America. —  Virginia 
ence  book  on  histology  that  we  know  I  3Iedical  Semi-3Iont]ihj. 

EDES  (ROBERT  T.).    TEXT-BOOK  OF  THERAPEUTICS  AND 

MATERIA  MEDICA.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50 ; 
leather,  $4.50. 
EDIS  (ARTHUR  W.).    DISEASES   OF   WOMEN.    A  Manual  for 
Students  and  Practitioners.   In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.    Cloth,  $3 ;  leather,  $4. 


LsA  Beothees  &  Co.,  Philadelphia  and  New  Yoek.       9 

EGBERT  (SENECA).  A  MANUAL  OF  HYGIENE  AND  SANI- 
TATION. In  one  12mo.  volume  of  359  pages,  with  63  illustrations. 
Just  ready.     Cloth,  Net,  $2.25. 


It  is  written  in  plain  language, 
and,  while  primarily  designed  for 
physicians,  it  can  be  studied  with 
protit  by  any  one  of  ordinary  intel- 


ligence. The  writer  has  adapted  it 
to  American  conditions,  and  his 
suggestions  are,  above  all,  practical. 
— The  New  York  Medical  Journal. 


ELLIS  (GEORGE  VEVER).  DEMONSTEATIONS  IN  ANATOMY. 

Eighth  edition.  Octavo,  716  pages,  with  249  engravings.  Cloth, 
$4.25 ;  leather,  $5.25. 

E30IET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNAECOLOGY.  Third  edition.  Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERIOHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY,  ^qq  American 
Text-Books  of  Dentistry,  page  2. 

EVANS  (DAVID  J.).  A  POCKET  TEXT-BOOK  OF  OBSTETRICS. 
In  one  handsome  12mo.  volume  of  about  300  pages,  with  many  illustra- 
tions. Cloth,  $1.50,  net.  Shortly.  Lea's  Series  of  Pocket  Text-books, 
edited  by  Been  B.  Gallaudet,  M.  D.    See  page  IS. 

FARQUHARSON  (ROBERT).    A  GUIDE  TO  THERAPEUTICS. 

Fourth  American  from  fourth  English  edition,  revised  by  Feank 
WOODBUEY,  M.  D.    In  one  12mo.  volume  of  581  pages.    Cloth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Seventh  edition,  thoroughly  revised 
by  Feedeeick  P.  Heney,  M.  D.  In  one  large  8yo.  volume'  of  1143 
pages,  with  engravings.     Cloth,  $5.00 ;  leather,  $6.00. 

The  work  has  well  earned  its  lead-  |  The  best  of  American  text-books 
ing  place  in  medical  literature. —  on  Practice. — Amer.lledico-Surgical 
Medical  Record.  Bulletin. 

A   MANUAL   OF  AUSCULTATION  AND  PERCUSSION ;  of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson,  M.  D. 
In  one  handsome  12mo.  volume  of  274  pages,  with  12  engravings. 

A    PRACTICAL    TREATISE    ON    THE    DIAGNOSIS    AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  edition 
enlarged.     In  one  octavo  volume  of  550  pages.     Cloth,  $4. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLO- 
RATION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DIS- 
EASES AFFECTING  THE  RESPIRATORY  ORGANS.  Second 
and  revised  edition.     In  one  octavo  volume  of  591  pages.   Cloth,  $4.50. 

MEDICAL  ESSAYS.   In  one  12mo,  vol,  of  210  pages.  Cloth,  $1.38. 

ON  PHTHISIS :  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 

A  Series  of  Clinical  Lectures.  In  one  8vo.  volume  of  442  pages. 
Cloth,  $3.50. 


10     Lea  Beothees  &  Co.,  Philadelphia  and  New  York. 

FOIiSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S. 
ON  CUSTODY  OF  THE  INSANE.  In  one  8vo.  vol.  of  108  pages. 
Cloth,  $1.50.  With  Cloxiston  on  Blental  Diseases  (new  edition,  see 
page  6)  $5.00,  net,  for  the  two  works. 

FOR3IULiARY,  POCKET,  see  page  32. 

FOSTER  (MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    New 

(6th)  and  revised  American  from  the  sixth  English  edition.    In  one 

large  octavo  volume  of  923  pages,  with  257  illustrations.     Cloth,  $4.50  ; 

leather,  $5.50. 

Unquestionably  the  best  book  that  I      This    single    volume  contains  all 

can  be  placed  in  the  student's  hands,    that  will  be  necessary  in  a  college 

and  as  a  work  of  reference  for  the  j  course,  and  all  that  the  physician 

busy  physician  it  can   scarcely  be    will  need  as  Avell. — Dominion  3Ied. 

excelled. —  The Phila.  Polyclinic.  Monthly. 

FOTHERGELIi  (J.  MIL.NER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  In  one  royal 
12mo.  volume  of  1061  pages,  with  168  engravings,  and  1  colored 
plate.     Cloth,  $2.75 ;  leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.R.).  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
GANS IN  THE  MALE.  In  one  very  handsome  octavo  volume  of 
238  pages,  with   25   engravings  and  8'  full-page  plates.      Cloth,  $2. 

It  is  an  interesting  work,  and  one  I  tive    and    brings    views     of   sound 


which,  in  view  of  the  large  and  ^ 
profitable  amount  of  work  done  in 
this  field  of  late  years,  is  timely  and 
well  needed. — Medical  Fortnightly. 
The  book  is  valuable  and  instruc- 


jjathology  and  rational  treatment  to 
many  cases  of  sexual  disturbance 
whose  treatment  has  been  too  often 
fruitless  for  good.  —  Annals  of 
Surgery. 


FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From  second  English  edition.  In  one  8vo.  volume  of  475 
pages.    Cloth,  $3.50. 

GALLAUDET  (HERN  B.).  A  POCKET  TEXT-BOOK  ON  SUR- 
GERY. In  one  handsome  12mo.  volume  of  about  400  pages,  with  many 
illustrations.  Shortly,  Lea's  Scries  of  Pocket  2'ext-books,  edited  by 
liKK.x  B.  Gallaudkt,  M.  D.     See  page  18. 

GANT  (FREDERICK  JAMES).   THE  STUDENT'S  SURGERY.    A 

Multum  in  Parvo.     In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3.75. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID 
HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.    Cloth,  $2.75. 

GIBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practi- 
tioners and  Students.     In  one  8vo.  vol.  profusely  illus.    Preparing. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     11 


GERRTSH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY. 
By  American  Autliors.  Edited  by  Frederic  II.  Gerrish,  M.  D.  In  one 
imp.  octavo  volume  of  015  paffcs,  with  950  illustrations  in  black  and 
colors.  JuKtready.  Clth, $0.50;  llexible  waterproof, $7;  leath.,$7.50,7/t'«. 

In  this,  the  first  representative  treatise  on  Anatomy  produced  in  America, 
no  effort  or  expense  has  been  spared  to  unite  an  authoritative  text  with  the 
most  successful  anatomical  pictures  which  have  yet  appeared  in  the  Avorld. 

The  editor  has  secured  the  co-operation  of  the  pi-ofessors  of  anatomy  in 
leading  medical  colleges,  and  with  them  has  prepared  a  text  conspicuous 
for  its  simplicity,  unity  and  judicious  selection  of  such  anatomical  facts  as 
bear  on  physiology,  surgery  and  internal  medicine  in  the  most  compre- 
hensive sense  of  those  terms.  The  authors  have  endeavored  to  make  a 
book  which  shall  stand  in  the  place  of  a  living  teacher  to  the  student,  and 
which  shall  be  of  actual  service  to  the  practitioner  in  his  clinical  Avork, 
emphasizing  the  most  imjiortant  subjects,  clarifying  obscurities,  helping 
most  in  the  parts  most  difficult  to  learn,  and  illustrating  everything  by  all 
available  methods. 

GOUL.D  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.     Cloth,  $2.  See  Student's  Series  of  Manuals,  p.  27. 

GRAY  (HENRY).     ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 

New  and  thoroughly  revised  American  edition,  much  enlarged  in  text, 
and  in  engravings  in  black  and  colors.  In  one  imperial  octavo  volume 
of  1239  pages,  with  772  large  and  elaborate  engravings  on  wood.  Price 
of  edition  with  illustrations  in  colors  :  cloth,  $7  ;  leather,  $8.  Price 
of  edition  with  illustrations  in  black :  cloth,  $6  ;  leather,  $7. 

This  is  the  best  single  volume 
upon  Anatomy  in  the  English 
language. - 

azine. 


University  lledical  Mag- 


Gray's  Anatomy  affords  the  student 
more  satisfaction  than  any  other 
treatise  with  which  we  are  familiar. 
— Buffalo  Med.  Journal. 

The  most  largely  used  anatomical 
text-book  published  in  the  English 
language. — Annals  of  Surgery. 

Particular  stress  is  laid  upon  the 
practical  side  of  anatomical  teach- 


ing, and  especially  the  Surgical 
Anatomy. —  Chicago  Med.  Recorder. 

Holds  first  place  in  the  esteem  of 
both  teachers  and  students. — llie 
Brooklyn  Medical  Journal. 

Tlie  foremost  of  all  medical  text- 
books.— Medical  Fortnightly. 

Gray's  Anatomy  should  be  the 
first  work  which  a  medical  student 
should  purchase,  nor  should  he  be 
without  a  copy  throughout  his  pro- 
fessional career. — Pittsburg  3Iedical 
Review. 


GRAY  (L.ANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND 
MENTAL  DISEASES.  For  Students  and  Practitioners  of  Medicine. 
New  (2d)  edition.  In  one  handsome  octavo  volume  of  728  pages,  with 
172  engravings  and  3  colored  plates.     Cloth,  $4.75;   leather,  $5.75. 


An  up-to-date  text-book  upon 
nervous  and  mental  diseases  com- 
bined. A  well-written,  terse,  ex- 
plicit, and  authoritative  volume 
treating  of  both  subjects  is  a  step  in 
the  direction  of  popular  demand. — 
I'he  Chicago  Clinical  Review. 

The  descriptions  of  the  various 


diseases  are  accurate  and  the  symp- 
toms and  differential  diagnosis  are 
set  before  the  student  in  such  a  way 
as  to  be  readily  comprehended.  The 
author's  long  experience  renders  his 
views  on  therapeutics  of  great  value. 
— 2%e  Journal  of  Nervous  and  3Ien- 
tal  Disease. 


12      Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY 
AND  MORBID  ANATOMY.  New  (8th)  American  from  the  eighth 
London  edition.  In  one  handsome  octavo  volume  of  582  pages,  with 
216  engravings  and  a  colored  plate.     Cloth,  $2.50,   net.    Just  ready. 

A  work  that  is  the  text-book  of 
probably  four-fifths  of  all  the  stu- 
dents of  pathology  in  the  United 
States  and  Great  Britain  stands  in 


of  the  day — as  much  so  almost  as 
Gray's  Anatomy.  It  is  fully  up-to- 
date  in  the  record  of  fact,  and  so  pro- 
fusely illustrated  as  to  give  to  each 


no  need  of  commendation.  The  work  j  detail  of  text  sufficient  explanation 


precisely  meets  the  needs  and  wishes 
of   the    general    practitioner. — The 
American  Practitioner  and  News. 
Green's  Pathology  is  the  text-book 


The  work  is  an  essential  to  the  prac- 
titioner— whether  as  surgeon  or  phys- 
ician. It  is  the  best  of  up-to-date 
text-books. —  Virginia3Ied.  3£onthly. 


GREENE  (WJIAAKM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Jfedical 
Chemistry.    In  one  12mo.  vol.  of  310  pages,  with  74  illus.   Cloth,  $1.75. 

GROSS  (SAI^rUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GRINDON  (JOSEPH).  A  POCKET  TEXT-BOOK  OF  SKIN 
DISEASES.  In  one  handsome  12mo.  volume  of  350  pages,  Avith 
many  illustrations.  Shortly.  Lea's  Series  of  Poclcet  Text-hooks,  edited 
by  Bern  B.  Gallaudet,  M.  D.     See  page*  18. 

HABERSHON  fS.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN 
Second  American  from  the  third  English  edition.  In  one  octavo  vol- 
ume of  554  pages,  with  11  engravings.     Cloth,  $3.50. 

HALL  (WLVFIELD  S.)  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
about  500  pages,  richly  illustrated.     In  press. 

HA301<TON  (ALLAN  3ICLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 

HARD  A  WAY  (W.  A.).    MANUAL  OF  SKIN  DISEASES.    New  (2d) 
edition.   In  one  12mo.  volume  of  560  pages,  with  40  illustrations  and 
2  plates.     Cloth,  $2.25,  net.     Just  ready. 
The  best  of  all  the  small  books  to    day  clinical  experience.     His  great 
recommend  to  students  and  practi-    strength  is  in  diagnosis,  descriptions 
tioners.     Probably   no   one    of   our  }  of  lesions  and   especially   in   treat- 
dermatologists  has  had  a  wider  every-  I  ment. — Indiana  Medical  Journal. 

HARE  (HOBART  AMORY).     PRACTICAL    DIAGNOSIS.    THE 
USE  OF  SYMPTOMS  IN  THE  DIAGNOSIS  OF  DISEASE.    New 
(4tli)  edition.   In  one  octavo  volume  of  623  pages,  with  205  engravings 
and  14  full-page  colored  plates.     Cloth,  $5.00,  net.     Just  ready. 
It  is  unique  in  many  respects,  and    he  will    become  a  better  diaguosti- 
the  author  has    introduced  radical    cian.    This  is  a  companion  to  Prac- 
changes  which  will  be  welcomed  by    tical    Therapeutics,    by     the    same 
all.     Anyone  who  reads   this  book    author,  and  it  is  difficult  to  conceive 
will  become  a  more  acute  observer,    of  any  two  works  of  greater  practical 
will  pav  more  attention  to  the  simple    utility. — Medical  Review. 
yet  indicative  signs  of  disease,  and  > 


Lea  Brothers  &  Co.,  Philadelphia  and  New  Yoek.     13 


HARE  (HOB ART  AMORY).    A   TEXT-BOOK  OF  PRACTICAL 

THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
New  (7th)  and  revised  edition.  In  one  octavo  volume  of  776  pages. 
Cloth,  $3.75,  net;  leather,  $4.50,  net. 

Its  classifications  are  inimitable,  I  it  can  be  readily  used  in  connection 
and  the  readiness  with  which  any-  with  Hare's  Practical  Diagnosis. 
thing  can  be  found  is  the  most  won-  For  the  needs  of  the  student  and 
dorful  achievement  of  the  art  of  in-  '  general  practitioner  it  has  no  equal. 


dexing.  This  edition  takes  in  all 
the  latest  discovered  remedies. — 
The  St.  Louis  Cliniqyie. 

The  great  value  of  the  work  lies 
in  the  fact  that  precise  indications 
for  administration  are  given.  A 
complete  index  of  diseases  and 
remedies  makes  it  an  easy  reference 
work.     It  has  been  arranged  so  that 


— Medical  Sentinel. 

The  best  planned  therapeutic  work 
of  the  century. — American  Prac- 
titioner and  Neivs. 

It  is  a  book  precisely  adapted  to 
the  needs  of  the  busy  practitioner, 
who  can  rely  upon  finding  exactly 
what  he  needs. —  The  National  3Ied- 
ical  Review. 


HARE  (HOBART  AMORY)  ON  THE  MEDICAL  COMPLICA- 
TIONS AND  SEQUELiE  OF  TYPHOID  FEVER.  Octavo,  276 
pages,  21  engravings  and  two  full- page  plates.  Just  ready.  Cloth, 
$2.40,  net. 

A  very  valuable  production.    One    read  with   great  profit. —  Cleveland 
of  the   very   best    products  of   Dr.  i  Journal  of  Medicine. 
Ilare  and  one  that  every  man  can  ' 

HARE  (HOBART  AMORY,  EDITOR).  A  SYSTEM  OF  PRAC- 
TICAL THERAPEUTICS.  In  a  series  of  contributions  by  eminent 
practitioners.  In  four  large  octavo  volumes  comprising  about  4500 
pages, with  about  550  engravings.  Vol.  IV.,  just  ready.  For  sale  by  sub- 
scription only.  Full  prospectus  free  on  application  to  the  Publishers. 
Regular  price.  Vol.  IV.,  cloth,  $6 ;  leather,  $7 ;  half  Russia,  $8. 
Price  Vol.  IV.  to  former  or  new  subscribers  to  complete  work,  cloth, 
$5  ;  leather,  $6 ;  half  Russia,  $7.  Complete  work,  cloth,  $20 ;  leather, 
$24  ;  half  Russia,  $28. 

The  great  value  of  Hare's  System  of  Practical  Therapeutics  has  led  to  a 
widespread  demand  for  a  new  volume  to  represent  advances  in  treatment 
made  since  the  publication  of  the  first  three.  More  than  fulfilling  this 
request  the  Editor  has  secured  contributions  from  practically  a  new  corps 
of  equally  eminent  authors,  so  that  entirely  fresh  and  original  matter  is 
ensured.  The  plan  of  the  work,  which  proved  so  successful,  has  been  fol- 
lowed in  this  new  volume,  which  will  be  found  to  present  the  latest  devel- 
opments and  applications  of  this  most  practical  branch  of  the  medical  art. 
The  entire  System  is  an  unrivalled  encyclopaedia  on  the  practical  parts  of 
medicine,  and  merits  the  great  success  it  has  won  for  that  reason. 


14     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  engravings.     Cloth,  $2.75 . 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one 


12mo.  volume  of  310  pages,  with  220  engravings.     Cloth,  $1,75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery  and  Obstetrics.  Second  edition.  In  one  royal 
12mo.  vol.  of  1028  pages,  with  477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  ( JAI>rES  R.).  A  MANUAL  OF  VENEREAL  DISEASES. 
New  (2d)  edition.  In  one  12mo.  volume  of  304  pages,  with  54  en- 
gravings.    Cloth,  $1.50,  net.    Just  ready. 

It  is  practical,  concise,  definite  j  ticularly  thorough,  and  may  be 
and  of  sufiicient  fulness  to  be  satis-  i-elied  upon  as  a  guide  in  the  man- 
factory. —  Chicago  Clinical  Review.    agemen{  of  this  class  of  diseases. — 

This  work  gives  all  of  the  prac-    Northwestern  Lancet. 
tically  essential  information    about        It  is  well  written,  up  to  date,  and 
the  three  venereal    diseases,    gon-    will  be  found  very   useful. — Inter- 
orrhcea,  the  chancroid  and  syphilis,    national  3Iedical  lUagazine. 
In  diagnosis  and  treatment  it  is  par-  ' 

HAYEM  (GEORGES)  AXD  HARE  (H.  A).  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof,  H,  A.  Hare,  M.  D.  In  one  octavo  volume 
of  414  pages,with  113  engravings.     Cloth,  $3. 

This  well-timed  up-to-date  volume  recognition.       Within    this     large 

is  particularly  adapted   to  the  re-  range    of     applicability,     physical 

quirements  of  the    general    practi-  agencies  when  compared  with  drugs 

tioner.      The    section    on     mineral  are  more  direct  and  simple  in  their 

waters  is  most  scientific  and  prac-  I  results.     Medical  literature  has  long 

tical.     Some  200  pages  are  given  up  been  rich  in  treatises  upon  medical 

to  electricity  and  evidently  embody  agents,   but  an  authoritative  work 

the  latest  scientific  information  on  upon    the    other   great    branch    of 

the  subject.     Altogether  this  work  therapeutics  has  until  now  been  a 

is  the  clearest  and  most  practical  aid  desideratum.  The  section  on  climate, 

to  the  study  of  nature's  therapeutics  rewritten   by   Prof.    Hare,  will,  for 

that  has  yet  come  under  our  obser-  the  first  time,  place   the  abundant 

vation. — The  Medical   Fortnightly,  resources  of  our  country  at  the  in- 

For  many  diseases  the  most  potent  telligent     command    of     American 

remedies  lie  outside  of  the  materia  practitioners. —  The    Kansas     City 

medica,  a  fact  yearly  receiving  wider  Medical  Index. 

HER3IAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.  vol.  of  198  pages,  with  80  engravings.  Cloth,  $L25.  See 
Student's  Series  oj[  Manuals,  page  27. 

HERMANN  (L..).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  engravings.     Cloth,  $1.50, 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     15 


HERRICK  (JAIMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In 
one  handsome  12mo.  volume  of  429  pages,  with  80  engravings  and  2 
colored  plates.     Cloth,  $2.50. 

Excellently    arranged,    practical,    microscopical  examination  to  be  em- 
concise,   up-to-date,   and  eminently    ployed  in  each  class.   The  technique 


well  fitted  for  the   use  of  the  prac- 
titioner as  well  as  of  the  student. — 
Chicago  3Ied.  Recorder. 
This  volume  accomplishes  its  ob- 


of  blood  examination, including  color 
analysis,  is  very  clearly  stated. 
Uranalysis  receives  adequate  space 
and  care. — JVeiv  York  Med.  Journal. 


jects  more  thoroughly  and  com-  |  We  commend  the  book  not  only  to 
pletely  than  any  similar  work  yet  the  undergraduate,  but  also  to  the 
published.  Each  section  devoted  to  physician  who  desires  a  ready  means 
diseases  of  special  systems  is  pre- 1  of  refreshing  his  knowledge  of  diag- 
ceded  with  an  exposition -of  the  nosis  in  the  exigencies  of  professional 
methods  of  physical,  chemical  and    life. — 3Iemphis  3Iedical  3[onthly. 

HILiLi   (BERKELEY).     SYPHILIS  AND  LOCAL    CONTAGIOUS 

DISORDERS.     In  one  8vo.  volume  of  479  pages.     Cloth,  $.3.25. 

HIL.L.IER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.).  HUMAN 
MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Limited  edition.  For  sale 
by  subscription  only. 

HOBIiYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS 
USED   IN   MEDICINE   AND  THE  COLLATERAL  SCIENCES. 

In  one  12mo.  volixme  of  520  double-columned  pages.  Cloth,  $1.50; 
leather,  $2. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN, 
INCLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  vol.  of  519  pp.,  with  illus.     Cloth,  $4..50. 

HOFFMANN  (FREDERICK)  AND  PO^VER  (FREDERICK  B.). 

A  MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the 
Examination  of  Medicinal  Chemicals  and  their  Preparations.  Third 
edition,  entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  A  new  American  from  the  fifth  English  edition. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  In  one  handsome  octavo  vol- 
ume of  lOOS.'pages,  with  428  engravings.     Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.  With  notes  and  additions  by  various 

American  authors.  Edited  by  John  H.  Packard,  M.  D.  In  three 
very  handsome  8vo.  volumes  containing  3137  double-columned  pages, 
with  979  engravings  and  13  lithographic  plates.  Per  volume,  clotn,  $6  ; 
leather,  $7  ;  half  Russia,  $7.50.    For  sale  by  subscription  only. 


16     Lea  Brothees  &  Co.,  Philadelphia  and  New  York. 


HORNER  (WrLLIA3I  E.).  SPECIAL  ANATOMY  AND  HIS- 
TOLOGY. Eighth  edition,  revised  and  modified.  In  two  large  8vo. 
volumes  of  1007  pages,  containing  320  engravings.    Cloth,  $6. 

HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one 
octavo  volume  of  308  pages.     Cloth,  $2.50. 

HUTCHISON  (ROBERT)  AND  RAINY  (HARRY).  CLINICAL 
METHODS.  A  GUIDE  TO  THE  PRACTICAL  STUDY  OF 
MEDICINE.  In  one  12mo.  volume  of  562  pages,  with  137  engrav- 
ings and  8  colored  plates.     Cloth,  $3.00. 


A  comprehensive,  clear  and  re- 
markably up  to-date  guide  to  clinical 
diagnosis.  The  illustrations  are 
plentiful  and  excellent.  As  exam- 
ples of  the  more  recent  additions  to 


medical  knowledge  which  receive 
recognition,  we  mention  Widal's 
test  for  typhoid  and  the  Neuron 
theory  of  the  nervous  system. — 
Jlontreal  Medical  Journal. 


HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo. 
volume  of  542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25. 
See  Series  of  Clinical  Manuals,  p.  25. 

HYDE  ( JA3IES  NEVINS).     A  PRACTICAL  TREATISE  ON  DIS- 

EASES  OF  THE  SKIN.  New  (4th)  edition,  thoroughly  revised. 
In  one  octavo  volume  of  815  pages,  with  110  engravings  and  12  full- 
page  plates,  4  of  which  are  colored.     Cloth,  $5.25 ;   leather,  $6.25. 


This  edition  has  been  carefully  re- 
vised, and  eveiy  real  advance  has 
been  recognized.  The  work  answers 
the  needs  of  the  general  practitioner, 
the  specialist,  and  the  student. —  The 
Ohio  Med.  Jour. 

A  treatise  of  exceptional  merit 
characterized  by  consci'^ntious  care 
and  scientific  accuracy. — Buffalo 
Med.  Journal. 

A  complete  exposition  of  our 
knowledge  of  cutaneous  medicine  as 
it  exists  to-day.  The  teaching  in- 
culcated throughout  is  sound  as  well 


as  practical. — The  American  Jour- 
nal of  the  Medical  Sciences. 

It  is  the  best  one-volume  work 
that  we  know.  The  student  who 
gets  this  book  will  find  it  a  useful 
investment,  as  it  will  well  serve  him 
when  he  goes  into  practice. —  Vir- 
ginia Medical  Semi-Monthly. 

A  full  and  thoroughly  modern 
text-book  on  dermatology.  —  The 
Pittsburg  3fedical  Rettetv. 

It  is  the  most  practical  hand- 
book on  dermatology  with  which  we 
are  acquainted. — The  Chicago  3Ied- 
ical  Recorder. 


JACKSON  (GEORGE  THOMAS).  THE  READY-REFERENCE 
HANDBOOK  OF  DISEASES  OF  THE  SKIN.  New  (3d)  edition. 
In  one  12mo.  volume  of  637  pages,  with  75  illustrations  and  a  colored 
plate.    Just  ready.     Cloth,  $2.50,  net. 

As  a  student's  manual,  it  may  be  [  Without  doubt  forms  one  of  the 
considered  beyond  criticism.  The  1  best  guides  for  the  beginner  in  der- 
book  is  singularly  full.— ,SV.  Louis  matology  that  is  to  be  found  in  the 
Medical  and  Surgical  Journal.  j  English  language. — Medicine. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  of  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographic  plates.    Cloth,  $6. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.     17 

JEWETT  (CHARIiES).  ESSENTIALS  OF  OBSTETRICS.    In  one 

12mo.  volume  of  356  pages,  with  80  engravings  and  3  colored  plates. 

Cloth,  $2.25.     Just  ready. 

An  exceedingly  useful  manual  for  [  ing  it  in  attractive  and  easily  tangi- 

student  and  practitioner.    The  au-  ;  ble  form.    The  book  is  well   illus- 

thor  has  succeeded  unusually  well    trated  throughout. — NashvtUe  Joar. 

in  condensing  the  text  and  in  arrang-    of  Medicine  and  Surgery. 

THE  PRACTICE  OF  OBSTETRICS.     By    American    Authors. 

One  large  octavo  volume  of  763  pages,  with  441  engravings  in  black 

and   colors,  and    22  full-page  colored   plates.    Just  ready.     Cloth, 

$5.00,  net ;  leather,  $6.00,  net. 

A  clear  and  practical  treatise  upon  '  the  book    abounds.      The  work  is 

obstetricsby  well-known  teachers  of  I  sure  to  be  popular    with    medical 

the  subject.     A  special    feature  of  i  students,  as  well  as  being  of  extreme 

this  work  would   seem    to    be   the  j  value  to    the    practitioner.  —  The 

excellent  illustrations    v/ith   which  |  Medical  Age. 

JONES  fC.  HANDFIELD).  CLINICAL  OBSERVATIONS  ON 
FUNCTIONAL  NERVOUS  DISORDERS.  Second  American  edi- 
tion.    In  one  octavo  volume  of  340  pages.     Cloth,  $3.25. 

JULER  rHENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 

AND   PRACTICE.      Second  edition.  In  one  octavo  volume  of  549 
pages,  with  201  engravings,  17  chromo-lithographic  plates,  test-types  of 
Jaeger  and  Snellen,  and  Holmgren's   Color-Blindness  Test.     Cloth, 
$5.50 ;  leather,  $6.50. 
The  volume  is  particularly  rich  in  \  color  blindness,   etc.    The    sections 
matter  of  practical  value,   such   as  '  devoted  to  treatment  are  singularly 
directions    for    diagnosing,    use    of   full  and  concise.— JfecZtca^  Age. 
instruments,  testing  for  glasses,  for  \ 

KING  f  A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Seventh  edition. 
In  one  12mo.  volume  of  573  pages,  with  223  illustrations.  Cloth, 
$2.50. 

From  first  to  finish  it  is  thoroughly  |  cyclopedias.  The  well-arranged 
practical,  concise  in  expression,  well  ;  index  renders  the  book  useful  to 
illustrated,  and  includes  a  statement  the  practitioner  who  is  in  haste  to 
of  nearly  every  fact  of  importance  '  refresh  his  memory.  —  Virginia 
discussed  in    obstetric    treatises  or  i  3Iedical  Seini- Monthly. 

KIRK   (EDWARD    C).      OPERATIVE  DENTISTRY.     Handsome 
octavo  of  700  pages,  with  751  illustrations.   Just  ready.    See  American 
Text-Books  of  Dentistry,  pa,ge  2. 
We  have  only  the  highest  praise    tempted.     We  can  heartily  recom- 
for  this  valuable  work.   It  is  replete    mend    it    to    the    profession. — The 
in  every  particular,   and  surpasses  j  Ohio  Dental  Journal. 
anything  of  the  kind  heretofore  at-  ) 

KLEIN  (E.).     ELEMENTS  OF  HISTOLOGY.     New  (5th)  edition.   In 
one  12mo.   volume  of  506  pages,  with  296  engravings.    Just  ready. 
Cloth,  $2.00,  net.     See  Student's  Series  of  Manuals,  page  27. 
It  is  the  most  complete  and  con-        This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has  yet    first  place  as  a  text-book  on   his- 

emanated  from  the  press. —  The 3fed-  ,  tologj.— Canadian  Practitioner. 

ical  Age.  ) 


18     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

L.ANDIS  (HENRY  G.).   THE  MANAGEMENT  OF  LABOR.   In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.   Cloth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468 
pages.     Cloth,  $7. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY- 
BOOK  OF  OPHTHALMIC  SURGERY.  Second  edition.  In  one 
octavo  volume  of  227  pages,  with  66  engravings.     Cloth,  $2.75. 

LEA'S  SERIEiS  OF  POCKET  TEXT-BOOKS,  edited  by  Bern 
B.  Gallaudet,  M.  D.  Covering  the  entire  field  of  Medicine  in  a 
series  of  16  very  handsome  cloth-hound  12mo.  volumes  of  .350-450 
pages  each,  profusely  illustrated.  Compendious,  clear,  trustworthy  and 
modern.     The  following  volumes  constitute  the  series. 

Coates'  Bacteriology  and  Hygiene.  Brockway's  Anatomy.  Collins 
and  Rockwell's  Physiology.  IMartix  and  Rockwell's  Chemistry 
and  Physics.  NiCHOLS  and  Vale's  Histology  and  Pathology, 
Schleif's  Materia  Medica,  Therapeutics,  Medical  Latin,  etc.  Mals- 
bary's  Practice  of  Medicine.  Collins'  Diagnosis.  Potts'  Nervous 
and  Mental  Diseases.  Gallaudet's  Surgery.  Likes'  Genito- 
urinary and  Venereal  Diseases.  Grtndon's  Dermatology.  Ballen- 
ger  and  Wippern's  Diseases  of  the  Eye,  Ear,  Throat  and  Nose. 
Evans'  Obstetrics.  Crockett's  Gynecology,  Tuttle's  Diseases  of 
Children. 

For  separate  notices  see  under  various  authors'  names, 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.     Per  volume,  cloth,  $3.00. 


—  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN  ; 
CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI- 
THE  ENDEMONIADAS;  EL  SANTO  NiRO  DE  LA  GUARDIA; 
BRIANDA   DE   BARDAXI.     12mo.,  522  pages.     Cloth,  $2.50. 

—  FORMULARY  OF  THE  PAPAL  PENITENTIARY.  In  one 
octavo  volume  of  221  pages,  with  frontispiece.    Cloth,  $2.50. 

—  SUPERSTITION  AND  FORCE ;  ESSAYS  ON  THE  WAGER 
OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 


—  STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Temporal 
Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.     Cloth,  $2.50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN   CHURCH.     Second  edition.     In  one  hand- 
some octavo  volume  of  685  pages.     Cloth,  $4.50. 

LEHMANN  (C.  G.).    A  MANUAL  OF  CHEMICAL  PHYSIOLOGY. 
In  one  8vo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 


Lea  Beotheks  &  Co.,  Philadelphia  and  New  York.     19 


LIKES  (SYLA^AN  H.).  A  POCKET  TEXT-BOOK  OF  GENITO- 
UEINAEY  AND  VENEREAL  DISEASES.  In  one  handsome 
12mo.  volume  of  about  350  pages,  with  many  illustrations.  Shortly. 
Lea's  Series  of  Pochct  Text-books,  edited  by  Bern  B.  Gallaudet, 
M.  D.     See  page  18. 

LiOOMIS  (ALFRED  L.)  AND  THOMPSON  (TT.  OILMAN, 
EDITORS).      A  SYSTEM   OF    PRACTICAL    MEDICINE.      In 

Contributions  by  Various  American  Authors.  In  four  very  hand- 
some octavo  volumes  of  about  900  pages  each,  fully  illustrated  in 
in  black  and  colors.  Complete  work  now  ready.  Per  volume,  cloth, 
$5;  leather,  $6;  half  Morocco,  $7.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  Publishers.  See  American 
System  of  Practical  Medicine,  page  2. 

LUFF  (ARTHUR  P.).     MANUAL  OF  CHEMISTRY,  for  the  use  of 

Students  of  Medicine.  In  one  12mo.  volume  of  522  pages,  with  36 
engravings.     Cloth,  $2.     See  Student's  Series  of  Manuals,  page  27. 

LYMAN  (HENRY  M.).    THE  PRACTICE  OF  MEDICINE.    In  one 

very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $4.75  ;  leather,  $5.75. 

Complete,  concise,  fully  abreast  of  Practical,  systematic,  complete  and 
the  times  and  needed  by  all  students  '•  well  balanced. —  Chicago  Med.  Re- 
and  pi-actitioners. —  Univ.  3 fed.  Mag.    corder. 

An  exceedingly  valuable  text-book.  ' 

LYONS  (ROBERT  D.).     A  TREATISE  ON  FEVER.     In  one  octavo 

volume  of  362  pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  ON  THE  NOSE  AND  THROAT. 
Handsome  octavo,  about  600  pages,  richly  illustrated.     Prejjaring. 


]>IAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA 
MEDICA.  New  (7th)  edition,  thoroughly  revised  by  H.  C.  C.  Maisch, 
Ph.  G.,  Ph.  D.  In  one  very  handsome  12mo.  volume  of  512  pages,  with 
285  engravings.    Just  ready.    Cloth,  $2.50,  net. 


Used  as  text-book  in  every  college 
of  pharmacy  in  the  United  States 
and  recommended  in  medical  col- 
leces. — American  Therapist. 

Noted  on  both  sides  of  the  Atlantic 
and  esteemed  as  much  in  Germany  as 


in  America.  The  work  has  no  equal. 
— Dominion  3Ied.  3Ionthly. 

The  best  handbook  upon  phar- 
macognosy of  any  published  in  this 
country. — Boston  3fed.  &  Sur.  Jonr. 


20    Lea  Beothees  &  Co.,  Philadelphia  and  New  York. 

MALSBARY    (GEORGE    E.).      A    POCKET    TEXT-BOOK     OF 

TIIEOEY  AXD  PRACTICE  OF  MEDICINE.  In  one  handsome 
r2mo.  volume  of  about  350  pages.  Shortly.  Lca^s  Series  of  Pocket 
Text-hooks,  edited   by  Bern  B.  Gallaudet,  M.  D.    See  page  18. 

MANTJAIiS.  See  Students  Quiz  Series,  page  27,  StudetiVs  Series  of 
Manuals,  page  27,  and  Series  of  Clinical  Manuals,  page  25. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  3Ianuals,  page  25. 

3IARTIN  (EDWARD).    A  MANUAL  OF  SURGICAL  DIAGNOSIS. 

In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.     Preparing. 

MARTIN  (WALTON)  AND  ROCKWELL  (WM.  H).  A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  PHYSICS.  In  one  hand- 
some 12mo.  volume  of  about  350  pages,  with  many  illustrations. 
Shortly.  Lea's  Series  of  Pocket  Text-hooks,  edited  by  Bern  B. 
Gallaudet,  M.  D.    See  page  18. 

MAY  (C.  H.).    MANUAL  OF  THE  DISEASES  OF  WOMEN.    For 

the  use  of  Students  and  Practitioners.  Second  edition,  revised  by  L. 
S.  Rau,  M.  D.  In  one  12mo.  volume  of  360  pages,  with  31  engrav- 
ings.    Cloth,  $1.75. 

MEDICAL  NEWS  POCKET  FOR^IULARY,  see  page  32. 

MITCHELL  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS 
DISEASES.  In  one  12mo.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.  Cloth,  $2.50.  Of  the  hundred  numbered  copies 
with  the  Author's  signed  title  page  a  few  remain ;  these  are  offered 
in  green  cloth,  gilt  top,  at  $3.50,  net. 

The  book  treats  of  hysteria,  recur-  contractions,  rotary  movements  in 
rent  melancholia,  disorders  of  sleep,  '  the  feeble  minded,  etc.  Few  can 
choreic  movements,  false  sensations  speak  with  more  authority  than  the 
of  cold,  ataxia,  hemiplegic  pain,  author. —  The  Journal  of  the  Ameri- 
treatment  of  sciatica,  erythromelal-  can  Medical  Association. 
gia,  reflex  ocularneurosis,  hysteric  [ 

MITCHEL.L  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  IN- 
JURIES   OF    NERVES    AND    THEIR    TREATMENT.     In  one 

handsome  12mo.  volume  of  239  pages,with  12  illustrations.  Cloth,  $1.75. 


Injuries  of  the  nerves  are  of  fre- 
quent occurrence  in  private  practice, 
and  often  the  cause  of  intractable 
and  painful  conditions,  conse- 
quently this  volume  is  of  especial 
interest.     Doctor  Mitchell  has  had 


access  to  hospital  records  for  tlie  last 
thirty  years,  as  well  as  to  the 
government  documents,  and  has 
skilfully  utilized  his  opportunities, 
—The  Med.  Age. 


MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  New  (2d) 
edition.  In  one  12mo.  volume  of  601  pages,  with  10  chromo-litho- 
graphic  plates  and  26    engravings.     Cloth,  $3.25,   net.    Just  ready. 

IVIULLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROL- 
OGY.    In  one  large  Svo.  vol.  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 


Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek.     21 


MUSSER  (JOHN  H.).   A  PRACTICAL  TREATISE  ON  MEDICAL 
DIAGNOSIS,  for  Students  and  Physicians.     New  (od)  edition,  thor- 
oughly revised.     In  one  octavo  volume  of  about  1000  pages,  with  about 
220  engravings  and  48  full-page  colored  plates.    In  press. 
Notices  of  previous  edition  are  appended. 
We  have  no  work  of  equal  value 

in   English.  —  University    Medical 


Magazine. 

His  descriptions  of  the  diagnostic 
manifestations  of  diseases  are  accu- 
rate. This  work  will  meet  all  the 
requirements  of  student  and  physi- 
cian.— The  3Iedical  News. 

From  its  pages  may  be  made  the 
diagnosis  of  every  paalady  that 
afflicts  the  human  body,  .including 
those  which  in  general  are  dealt 
with  only  by  the  specialist. — North- 
western Lancet. 


It  so  thoroughly  meets  the  precise 
demands  incident  to  modern  research 
that  it  has  been  adopted  as  a  leading 
text-book  by  the  medical  colleges 
of  this  country. — North  American 
Practitioner. 


Occupies  the  foremost  place  as  a 
thorough,  systematic  treatise. —  Ohio 
Medical  Journal. 

The  best  of  its  kind,  invaluable  to 
the  student,  general  practitioner  and 
teacher. — Montreal  MedicalJ our  nal. 


NATIONAL  DISPENSATORY.  See  StUle,  Maisch  &  Caspari,  p.  27. 

NATIONAL  FOR]\rLrLAR,Y.  See  Stille,  Maisch  &  Caspari's  National 
Dispensatory,  page  27. 

NATIONAL  IMEDICAL  DICTIONARY.     See  Billings,  page  4. 

NETTLESHEP  (E.).  DISEASES  OF  THE  EYE.    New  (5th)  American 
from  sixth  English  edition,  thoroughly  revised.     In  one  12mo.  volume 
of  521  pages,  with  161  engravings,  and  2  colored  plates,  test-types, 
formulae  and  color-blindness  test.     Cloth,  $2.25.    Just  ready. 
By  far  the  best  student's  text-book  •  English     language.  —  Journal      of 
on  the  subject  of  ophthalmology  and  Medicine  and  Science. 
is  conveniently  and    concisely    ar-       The  present  edition  is  the  result 
ranged. — The  Clinical  Review.  of  revision  both  in    England  and 

It  has  been  conceded  by  ophthal-  America,  and  therefore  contains  the 
mologists  generally  that  this  work  latest  and  best  ophthalmological 
for  compactness,  practicality  and  ideas  of  both  continents. — The  Phy- 
clearness    has  no   superior    in  the  sician  and  Surgeon. 

NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT- 
BOOK OF  HISTOLOGY  AND  PATHOLOGY.  In  one  handsome 
12mo.  volume  of  about  350  pages,  with  many  illustrations.  In  press. 
Lea's  Series  of  Pocket  Text-books,  edited  by  Been  B.  Gallaudet, 
M.  D.     See  page  18. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXTBOOK  OF 

OPHTHALMOLOGY.     In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5  ;  leather,  $6. 
A  safe  and  admirable  guide,  well 


qualified  to  furnish  a  working 
knowledge  of  ophthalmology.  — 
Johns  Hopkins  Hospital  Bulletin. 

It  is  practical  in   its  teachings. 
We  unreservedly  endorse  it  as  the 


best,  the  safest  and  the  most  compre- 
hensive volume  upon  the  subject  that 
has  ever  been  offered  to  the  Amer- 
ican medical  public. — Annals  of 
Ophthalmology  and  Otology. 


22     Lea  Beothbes  &  Co.,  Philadelphia  and  New  Yoek. 


OWEN    (EDMUND).      SURGICAL    DISEASES    OF    CHILDREN. 

In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 


PARK  (ROSWEIili).  A  TREATISE  ON  SURGERY  BY  AMERI- 
CAN AUTHORS.  New  and  condensed  edition.  Jii><f  rcudy.  In  one 
royal  octavo  volume  of  about  1250  pages,  with  about  GOO  engravings 
and  37  full-page  plates.  Cloth,  $6.00,  net;  leather,  $7.00,  net. 
^©''This  work  is  also  pul>li shed  in  a  larger  edition,  comprising  two 
volumes.  Volume  I.,  General  Surgery,  799  pages,  with  356  engravings 
and  21  full-page  plates,  in  colors  and  monochrome.  Volume  II., 
Special  Surgery,  800  pages,  with  430  engravings  and  17  full-page 
plates,  in  colors  and  monochrome.  Per  volume,  cloth,  $4.50 ;  leather, 
$5.50,  net. 


The  work  is  fresh,  clear  and  practi- 
cal, covering  the  ground  thoroughly 
yet  briefly,  and  well  arranged  for 
rapid  reference,  so  that  it  will  be  of 
special  value  to  the  student  and  busy 
practitioner.  The  pathology  is 
broad,  clear  and  scientific,  while  the 
suggestions  upon  treatment  are 
clear-cut,  thoroughly  modern  and 
admirably  resourceful. — Johns  Hop- 
kins Hospital  Bulletin. 

The  latest  and  best  work  written 
upon  the  science  and  art  of  surgery. 
Columbus  Medical  Journal. 

The  illustrations  are  almost  en- 
tirely new  and  executed  in   such   a 


way  that  they  add  great  force  to  the 
text. — The  Chicago  Medical  Re- 
corder. 

The  various  writers  have  em- 
bodied the  teachings  accepted  at 
the  present  hour. — The  North  Amer- 
ican Practitioner. 

Both  for  the  student  and  practi- 
tioner it  is  most  valuable.  It  is 
thoroughly  practical  and  yet  thor- 
oughly scientific. — Medical  News. 

A  truly  modern  surgery,  not  only 
in  pathology,  but  also  in  sound 
surgical  therapeutics.  —  New  Or- 
leans Med.  and  Surgical  Journal. 


PARK  (WILLIAM  H.).     BACTERIOLOGY  IN  MEDICINE  AND 

SURGERY.     12mo.,  about  550  pages,  fully  illustrated.     In  press. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS 
CLINICAL  HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.    In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 


PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OB- 
STETRICS. Third  edition.  In  one  handsome  octavo  volume  of 
677  pages,  with  267  engravings  and  2  colored  plates.  Cloth,  $4.25 ; 
leather,  $5.25. 


In  the  foremost  rank  among  the 
most  practical  and  scientific  medical 
works  of  the  day. — Medical  News. 

It  ranks  second  to  none  in  the 
English  language. — Annals  of  Gyne- 
cology and  Pediatry. 

The  book  is  complete  in  every  de- 
partment, and  contains  all  the  neces- 
sary detail  required  by  the  modern 


practising  obstetrician.  —  Interna- 
tional Medical  Magazine. 

Parvin's  work  is  practical,  con- 
cise and  comprehensive.  We  com- 
mend it  as  first  of  its  class  in  thfe 
English  \2d\g\x2igQ.— Medical  Fort- 
nightly. 

It  is  an  admirable  text-book  in 
every  sense  of  the  word.— Nashville 
Journal  of  Medicine  and  Surgery. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     23 

PEPPER'S  SYSTP:M  of  medicine.    See  page  3. 

PEPPER  (A.  J.).    FORENSIC  MEDICINE.   In  press.    See  Student's 
Series  0/  Manuals,  page  27. 

SURGICAL  PATHOLOGY.     In  one  12mo.  volume  of  511  pages, 

with  81  engravings.   Cloth,  $2.   See  Student's  Series  of  Manuals,  p.  27. 

PICK  (T.  PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12rao,  volume  of  530  pages,  with  93  engravings.      Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

PIjAYFAIR  (W.   S.).      a  TREATISE  ON    THE  SCIENCE   AND 
PRACTICE  OF  MIDWIFERY.     Seventh  American  from  the  ninth 
English  edition.      In   one  octavo   volume   of  700    pages,    with    207 
engravings  and  7  plates.     Cloth,  $3.75  nrt ;  leather,  $4.75,  net.     Just 
ready. 
In  the  numerous  editions   wliich 
have  appeared  it  has  been  kept  con- 
stantly in  the  foremost  rank.     It   is 
a  work  which  can  be  conscientiously 
recommended   to   the    profession. — 
The  Albany  Medical  Annals. 

This  work   must  occupy   a  fore- 
most place  in  obstetric  medicine   as  j  3Iedical  Fortnightly. 
a  safe  guide  to  both  student  and  I 


obstetrician.  It  holds  a  place  among 
the  ablest  English-speaking  authori- 
ties on  the  obstetric  art. — Buffalo 
Medical  and  Surgical  Journal. 

An  epitome  of  the  science  and 
practice  of  midwifery,  which  em- 
bodies  all   recent  advances.  — ■  The 


THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRA- 
TION AND  HYSTERIA.  In  one  12mo.  volume  of  97  pages. 
Cloth,  $1. 

POCKET  FORMULARY,  see  page  32. 

POCKET  TEXT-BOOKS,  see  page  18. 

POIilTZER  f  ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
EAR  AND   AD.IACENT   ORGANS.     Second   American   from   the 
third   German   edition.      Translated  by   OsCAR  DODD,    M.  D.,   and 
edited  by  Sir  William  Dalby,  F.  R.  C.  S.    In  one  octavo  volume  of 
748  pages,  with  330  original  engravings.     Cloth,  $5.50. 
The   anatomy  and    physiology  of   ment  are  clear  and  reliable.     We 
each    part  of  the   organ   of  hearing    can  confidently  recommend  it,  for  it 
are    carefully   considered,  and   then    contains  all  tbat  is  known  upon  the 
follows  an  enumeration  of  the   dis-    subject. — London  Lancet. 
eases  to  which  that  special   part  of       A   safe  and   elaborate  guide  into 
the  auditory  apj^aratus  is  especially  1  every  part    of   otology. — American 
liable.     The    indications    for  treat-  1  Journal  of  the  Sledical  Sciences. 

POTTS  (CHARLES  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS 
AND  MENTAL  DISEASES.  In  one  handsome  12mo.  volume  of 
about  450  pages.  Shortly.  Lra's  Series  of  Pocket  Text-books,  edited  by 
Bern  B.  Gallatjdet,  M.  D.    See  page  18. 

PROGRESSIVE  MEDICINE,  see  page  32. 

PURDY  (CHARLES  W.^.  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  288 
pages,  with  18  engravings.     Cloth,  $2. 


24     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

PYE-SMITH  (PHILIP  H.).     DISEASES  OF  THE  SKIN.     In  one 

12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2. 

QUIZ  SERIES.     See  Student's  Quiz  Series,  page  27. 

RALFE    (CHARLES   H.).      CLINICAL      CHEMISTRY.     In    one 

12mo.  volume  of  314  pages,  with  16  engravings.     Cloth,  $1.50.     See 
Student's  Series  of  Ilanuals,  page  27. 

RA3ISBOTHA3I  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND  SURGERY.  In  one 
imperial  octavo  volume  of  640  pages,  with  64  plates  and  numerous 
engravings  in  the  text.     Strongly  bound  in  leather,  $7. 

REICHERT  (EDWARD  T.).    A  TEXT-BOOK  ON  PHYSIOLOGY. 

In  one  handsome  octavo  volume  of  about  800  pages,  richly  illustrated. 
Preparing. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. New  (5th)  edition,  thoroughlv  revised.  In  one  12mo.  vol- 
ume of  326  pages.     Cloth,  $2. 

A  clear  and  concise  explanation  that  the  work  has  met  with  general 

of  a  difficult  subject.     We  cordially  favor.    This  is  further   established 

recommend  it. — The  London  Lancet,  by  the  fact  that  it  has   been   trans- 

The  book  is  equally  adapted  to  the  lated  into  German  and  Italian.    The 

student  of  chemistry  or  the  practi-  treatise  is  especially  adapted  to  the 

tioner  who  desires  to  broaden  his  laboratory  student.    It  ranks  unusu- 

theoretical  knowledge  of  chemistry,  ally  high  among  the  works   of  this 

— New  Orleans  Med.  and  Surg.  Jour,  class.  This  edition  has  been  brought 

The  appearance  of  a  fifth  edition  fully  up  to  the    times. — American 

of  this  treatise  is  in  itself  a  guarantee  3Iedico-Surgical  Bulletin. 

RICHARDSON  (BENJA3IIN  WARD).  PREVENTIVE  MEDI- 
CINE.    In  one  octavo  volume  of  729  pages.     Cloth,  $4 ;  leather,  $5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  New  (2d)  edition.  In  one  octavo  volume  of 
about  800  pages,  with  about  500  engravings.     Shortly. 

THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting 

Room  and  in  preparing  for  Examinations.     In  one  16mo.  volume  of 
196  pages.    Limp  cloth,  75  cents. 

ROBERTS  (SIR  \I^ILLIA3f).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES,  INCLUDING  URINARY 
DEPOSITS.  Fourth  American  from  the  fourth  London  edition.  In 
one  very  handsome  8vo.  vol.  of  609  pp.,  with  81  illus.     Cloth,  $3.50. 

ROBERTSON  (J.  MCGREGOR).  PHYSIOLOGICAL  PHYSICS. 
In  one  12mo.  volume  of  537  pages,  with  219  engravings.  Cloth,  $2. 
See  Student's  Series  of  Manuals,  page  27. 

ROSS  f  JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  handsome  octavo  volume  of  726  pagee, 
with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50. 

SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES, 
PRACTICAL  AND  CLINICAL.  In  one  12mo.  volume  of  551  pages, 
with  18_ typical  engravings.  Cloth,  $2.  See  Series  of  Clinical  Man- 
uals, page  25. 


Lea  Bkothers  &  Co.,  Philadelphia  and  New  Yoek.     25 

SCHAFER  (EDWARD  A.).  TPIE  ESSENTIALS  OF  HISTOL- 
OGY. DESCllIPTiVE  AND  PRACTICAL.  For  the  use  of  Students. 
New  (5th)  editiou.  lu  one  handsome  octavo  volume  of  359  pages, 
with  392  illustrations.     Cloth,  $3.00,  net.     Just  ready. 


The  most  satisfactory  elementary 
text-book  of  histology  in  the  Eng- 
lish language. — The  Boston  Med.  and 
Sur.  Jour. 


Nowhere  else  will  the  same  very 
moderate  outlay  secure  as  thoroughly 
useful  and  interesting  an  atlas  of 
structural  anatomy. —  The  American 
Journal  of  the 3£edical  Sciences. 

A  COURSE  OF  PRACTICAL  HISTOLOGY.    New  (2d)  edition. 

In  one  12mo.  volume  of  307  pages,  with  59  engravings.   Cloth,  $2.25. 

SCHLEIF  (WTLIilAM).  MATERIA  MEDICA,  THERAPEUTICS, 
PRESCRIPTION  AVRITING,    MEDICAL   LATIN,  ETC.     12mo., 

352   pages.     Cloth,   $1.50,   'iict.     Just  ready.     Lea's  Series  of  Pocket 
Text-books.    Edited  by  Bekn  B.  Gallaudet,  M.  D.     See  page  IS. 

SCHMITZ  AND  ZUMPT'S  CLiASSICAIi  SERIES.  Advanced 
Latin  Exercises.  Cloth,  GO  cts.  Schmidt's  Elementary  Latin  Exer- 
cises. Cloth,  50  cents.  Sallust.  Cloth,  60  cents.  Nepos.  Cloth,  60 
cents.     Virgil.     Cloth,  85  cents.     Curtius.     Cloth,  80  cents. 

SCHOFIELD    (ALFRED    T.).      ELEMENTARY    PHYSIOLOGY 

FOR  STUDENTS.        In  one  12mo.  volume  of  380  pages,  with  227 
engravings  and  2  colored  plates.     Cloth,  $2. 

SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY 
MASSAGE  AND  METHODICAL  MUSCLE  EXERCISE.  Octavo 
volume  of  274  pages,  with  117  engravings. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edi- 
tion. In  one  octavo  volume  of  268  pages,  with  13  plates,  10  of  which 
are  colored,  and  9  engravings.     Cloth,  $2. 

SERIES  OF  CLiINICAJj  MANUALS.  A  Series  of  Authoritative 
Monographs  on  Important  Clinical  Subjects,  in  12mo.  volumeis  of  about 
550  pages,  well  illustrated.  The  following  volumes  are  now  ready : 
Yeo  on  Food  in  Health  and  Disease,  new  (2d)  edition,  $2.50;  Carter 
and  Frost's  Ophthalmic  Surgery,  $2.25 ;  Hutchinson  on  Syphilis, 
$2.25;  Marsh  on  Diseases  of  the  Joints,  $2;  Owen  on  SurgicalDis- 
eases  of  Children,  $2;  Pick  on  Fractures  and  Dislocations,  $2;  Savage 
on  Insanity  and  Allied  Neuroses,  $2. 
For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  STUDENT'S  MANUALS.     See  page  27. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICRO- 
SCOPICAL AND  CHEMICAL  MP^THODS.  New  (2d)  edition.  In 
one  very  handsome  octavo  volume  of  530  pages,  with  135  engravings 
and  14  full-page  colored  plates.     Cloth,  $3.50.    Just  ready. 

In  all  respects  entirely  up  to  date. 
— Medical  Jiecord. 

The  chapter  on  examination  or 
the  urine  is  the  most  complete  and 
advanced  that  we  know  of  in  the 
English  language. —  Canadian  Prac- 
titioner. 


This  book  thoroughly  deserves  its 
success.  It  is  a  very  complete,  authen- 
tic and  useful  manual  of  the  micro- 
scopical and  chemical  methods 
which  are  employed  in  diagnosis. 
Very  excellent  colored  plates  illus- 
trate this  work. — New  York  Medical 
Journal. 


26     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures 
and  Laboratory  Work  for  Beginners  in  Chemistry.  A  Text-book 
specially  adapted  for  Students  of  Pharmacy  and  Medicine.  New  (6th) 
.j.-x:-_      T_   —  o„„  „„i ^  ^'>Q  pages,  with  46  engravings  and  8 


edition.  In  one  8vo.  volume  of 
plates  showing  colors  of  64  tests. 
It  is  difficult  to  see  how  a  better 
book  could  be  constructed.  No  man 
who  devotes  himself  to  the  practice 
of  medicine  need  know  more  about 
chemistry  than  is  contained  between 


Cloth,  $3.00,  net.     Just  ready. 
the  covers  of  this  book. — The  North- 
western Lancet. 

Its  statements  are  all  clear  and  its 
teachings  are  practical. —  Virginia 
Med.  llonthly. 


SL.ADE   (D.   D.).     DIPHTHERIA;    ITS    NATURE   AND    TREAT- 
MENT. Second  edition.  In  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 


S3IITH  (EDWARD). 

DIABLE  STAGES. 


LEWIS  1 


CONSUMPTION ;  ITS  EARLY  AND  REME- 

In  one  8vo.  volume  of  253  pp.     Cloth,  $2.25. 


TREATISE  ON  THE  DISEASES  OF  IN- 

Eighth  edition,  thoroughly  revised 

In  one  large  8vo.  volume  of  983 

4  full-page  plates.     Cloth,  $4.50; 


SMITH  (J 

FANCY  AND  CHILDHOOD. 

and  rewritten  and  much  enlarged 

pages,   with   273  engravings  and 

leather,  $5.50. 
A  safe  guide  for  students  and  phy- 
sicians.— The  Am.  Jour,  of  Obstetrics. 
For  years  the  leading  text-book  on 
children's    diseases  in    America. — 
Chicago  Medical  Recorder. 

SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thor- 
oughly revised  edition.  In  one  octavo  volume  of  892  pages,  with 
1005  engravings.     Cloth,  $4  ;  leather,  $5. 


The  most  complete  and  satisfac- 
tory text-book  with  which  we  are 
acquainted. — American  Gynecologi- 
cal and  Obstetrical  Journal. 


One  of  the  most  satisfactory  works 
on  modern  operative  surgery  yet 
published.     The  book  is  a  compen- 


dium for  the  modern  surgeon. — Bos- 
ton 3Iedical  and  Surgical  Journal. 


SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMA- 
TOLOGY. In  one  handsome  octavo  volume  of  462  pages,  with  en- 
gravings and  11  full-page  plates,  5  of  which  are  in  colors.  Cloth,  $4.00. 
Just  ready. 


A  clear  and  lucid  summary  of 
what  is  known  of  climate  in  relation 
to  its  influence  upon  human  beings. 
—  The  Therapeutic  Gazette. 

The  book  is  admirably  planned, 
clearly  written, and  the  author  speaks 
from  an  experience  of  thirty  years  as 


an  accurate  observer  and  practical 
therapeutist. — Maryland  Med.  Jour. 
Every  practitioner  of  medicine 
should  possess  himself  of  a  copy  and 
study  it,  and  we  are  sure  he  will 
never  regret  it. — ^S"^.  Louis  Medical 
and  Surgical  Journal. 


STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  163  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth    and 

revised  edition.      In   two  octavo  volumes,  containing    1936    pages. 
Cloth,  $10 ;  leather,  $12. 


Lea  Brothkks  &  Co.,  Philadelphia  and  New  Yoek.     27 


STILLE  (ALFRED),  MAISCH  (JOHN  M.)  AND  CASPARI 
(CHAS.  JR.)-  THE  NATIONAL  DISPENSATORY:  Containing 
the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of 
Medicines,  including  those  recognized  in  the  latest  Pharmacopoeias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  refer- 
ences to  the  French  Codex.  Fifth  edition,  revised  and  enlarged, 
including  the  new  U.  S.  Pharmacopoeia,  Seventh  Decennial  Revision. 
With  Supplement  containing  the  new  edition  of  the  National  Formu- 
lary. In  one  magnificent  imperial  octavo  volume  of  about  2025  pages, 
with  320  engravings.  Cloth,  $7.25;  leather,  $8.  With  ready  reference 
Thumb-letter  Index.     Cloth,  $7.75  ;  leather,  $8.50. 

STIMSON  (LEWIS  A.).    A  MANUAL  OF  OPERATIVE  SURGERY. 

New  (3d)  edition.     In  one  royal  12mo.  volume  of  614  pages,  with  306 
engravings.     Cloth,  $3.75. 


A  useful  and  practical  guide  for 
all  students  and  practitioners. — Am. 
Journal  of  the  Medical  Sciences. 


The  book  is  worth  the  price  for  the 
illustrations  alone. — Ohio  Medical 
Journal. 


STIMSON  (LEWIS  A.). 

DISLOCATIONS.   In 

with  326  engravings  and  20  plates 
leather,  $6.00,  net. 


A  TREATISE  ON  FRACTURES    AND 

one  handsome   octavo  volume    of  831  pages, 


Just  ready.     Cloth,  $5.00,  net ; 


Preeminently  the  authoritative 
text-book  upon  the  subject.  The 
vast  experience  of  the  author  gives 
to  his  conclusions  an  unimpeachable 
value.  The  work  is  profusely  il- 
lustrated. It  will  be  found  indis- 
pensable to  the  student  and  the  prac- 
titioner alike. — :Z7te  Medical  Age. 


Taken  as  a  whole,  the  work  is  the 
best  one  in  English  to-day. — St. 
Louis  Medical  and  Surgical  Journal . 

Pointed,  practical,  comprehensive, 
exhaustive,  authoritative,  well  writ- 
ten and  well  arranged. — Denver 
Medical  Times. 


STUDENT'S  QUIZ  SERIES.  Thirteen  volumes,  convenient,  author- 
itative, well  illustrated,  handsomely  bound  in  cloth.  1.  Anatomy 
(double  number);  2.  Physiology;  3.  Chemistry  and  Physics;  4. Histol- 
ogy, Pathology,  and  Bacteriology;  5.  Materia  Medica  and  Thera- 
peutics ;  6.  Practice  of  Medicine ;  7.  Surgery  (double  number);  8.  Genito- 
urinary and  Venereal  Diseases ;  9.  Diseases  of  the  Skin;  10.  Diseases 
of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics;  12.  Gynecology; 
13.  Diseases  of  Children.  Price,  $1  each,  except  Nos.  1  and  7, 
Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at 
$1.75  each.     Full  specimen  circular  on  application  to  publishers. 

STUDENT'S  SERIES  OF  MANUALS.  12mos.  of  from  300-540 
pages,  profusely  illustrated,  and  bound  in  red  limp  cloth.  Hp;rm:an's 
First  Lines  in  Midwifery,  $1.25;  Luff's  Manual  of  Chemistry,  $2; 
Bruce's  Materia  Medica  and  Therapeutics  (sixth  edition),  $1.50.  net. 
Bell's  Comparative  Anatomy  and  Physiology,  $2 ;  Robert- 
son's Physiological  Physics,  $2;  Gotjld's  Surgical  Diagnosis,  $2; 
Klein's  Elements  of  Histology  (5th  edition),  $2.00,  net ;  Pepper's 
Surgical  Pathology,  $2 ;  Treves'  Surgical  Applied  Anatomy,  .$2 ; 
Ralfe's  Clinical  Chemistry,  $1.50;  and  Clarke  and  Lockwood's 
Dissector's  Manual,  $1.50.  The  following  is  in  press :  Pepper's 
Forensic  Medicine. 
For  separate  notices,  see  under  yarious  author's  names. 


28     Lka  Bbothees  a  Co.,  Philadelphia  and  New  Yobk. 


STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE 
OVARIES  AND  FALLOPIAN  TUBES.  Including  Abdominal 
Pregnancy.  In  one  12mo.  volume  of  513  pages,  with  119  engravings 
and  5  colored  plates.     Cloth,  $3. 

TAIT  (LAWSON).  DISEASES  OF  WOMEN  AND  ABDOMINAL 
SURGERY.  In  two  handsome  octavo  volumes  Vol.  I.  contains  546 
pages  and  3  plates.    Cloth,  $3. 

TANNER  (THOMAS  HAWKES)  ON  THE  SIGNS  AND  DIS- 
EASES OF  PREGNANCY.  From  the  second  English  edition.  In 
one  octavo  volume  of  490  pages,  with  4  colored  plates  and  16  engrav- 
ings.    Cloth,  $4.25. 

TAYLOR   (ALFRED   S.).     MEDICAL    JURISPRUDENCE.     New 

American  from  the  twelfth  English  edition,  specially  revised  by  Clark 
Bell,  Esq.,  of  the  N.  Y.  Bar.  In  one  8vo.  vol.  of  831  pages,  with  54 
engrs.  and  8  full-page  plates.  Cloth,  $4.50;  leather,  $5.50  Jmt  ready. 
To  the  student,  as  to  the  physician,    nesses,  it  strongly  behooves  them  to 


we  would  say,  get  Taylor  first,  and 
then  add  as  means  and  inclination 
enable  you. — American  Practitioner 
and  News. 

It  is  the  authority  accepted  as 
final  by  the  courts  of  all  English- 
speaking  countries.  This  is  the  im- 
portant consideration  for  medical 
men,  since  in  the  event  of  their 
being  summoned  as  experts  or  wit- 


be  prepared  according  to  the  princi- 
ples and  practice  everywhere  ac- 
cepted. The  work  will  be  found  to 
be  thorough,  authoritative  and 
modern. — Albany  Laic  Journal. 

Probably  the  best  work  on  the 
subject  written  in  the  English  lan- 
guage. The  work  has  been  thor- 
oughly revised  and  is  up  to  date. — 
Pacific  Medical  Journal. 


ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDI- 
CAL JURISPRUDENCE.  Third  American  from  the  third  London 
edition.  In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5.50 ;  leather,  $6.50. 

TAYLOR   (ROBERT  W.).      THE    PATHOLOGY   AND    TREAT- 
MENT OF   VENEREAL   DISEASES.     New  (2d)  edition.     In  one 
very  handsome  octavo  volume  of  about  700  pages,  with  about  200  en- 
gravings and  6  colored  plates.    In  press. 
Notices  of  previous  edition  are  appended. 
By  long  odds  the  best   work   on    diseases  that  has  in  recent  years^  ap- 


venereal  diseases. — Louisville  Jledi- 
cal  Monthly. 

In  the  observation  and  treatment 
of  venereal  diseases  his  experience 
has  been  greater  probably  than  that 
of  any  other  practitioner  of  this  con- 
tinent.— NewYork  3Iedical  Journal. 

The  clearest,  most  unbiased  and 
ably  presented  treatise  as  yet  pub- 
lished on  this  vast  subject. — The 
Medical  News. 

Decidedly  the  most  important  and 
authoritative  treatise    ou    venereal 


peared  in  English. — American  Jour- 
nal of  the  Medical  Sciences. 

It  is  a  veritable  storehouse  of  our 
knowledge  of  the  venereal  diseases. 
It  is  commended  as  a  conservative, 
practical,  full  exposition  of  the 
greatest  value. — Chicago  Clinical 
Review. 

The  best  work  on  venereal  dis- 
eases in  the  English  language.  It 
is  certainly  above  everything  of  the 
kind. —  The  St.  Louis  Medical  and 
Surgical  Journal. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     29 

TAYLOR  (ROBERT  W.).     A  PRACTICAL  TREATISE  ON  SEX- 
UAL   DISORDERS   IN   THE   MALE  AND   FEMALE.    In    one 

8vo.  vol.  of  448  pp.,  with  73  engravings  and  8  colored  plates.     Cloth, 
$3.    NeL 
The  author  has  presented  to  the    followed,  will  be  of  unlimited  value 


to    both   physician    and   patient.- 
Medical  News. 


profession  the  ablest  and  most  scien 
tific  work  as  yet  published  on  sexual 
disorders,  and  one  which,  if  carefully 

A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 

Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  x  18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  fine  engravings  and  425 
pages  of  text.  Complete  work  now  ready.  Price  per  part,  sewed  in 
heavy  embossed  paper,  $2.50.  Bound  in  one  volume,  half  Russia, 
$27  ;  half  Turkey  Morocco,  $28.  For  sale  hy  subscription  only.  Address 
the  publishers.     Specimen  plates  by  mail  on  receipt  of  ten  cents. 

TAYLOR  (SEYMOUR).    INDEX  OF  MEDICINE.    A  Manual  for 

the  use  of  Senior  Students  and  others.  In  one  large  12mo.  volume  of 
802  pages.     Cloth,  $3.75. 

THOMAS  (T.  GAILLiARD)  AND  MUNDE'(PAUL.  F.).  A  PRAC- 
TICAL TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth 
edition,  thoroughly  revised  by  Paul  F.  Munde,  M.  D.  In  one 
large  and  handsome  octavo  volume  of  824  pages,  with  347  engravings. 
Cloth,  $5 ;  leather,  $6. 
The  best  practical  treatise  on  the 

subject  in    the    English    language. 

It  will  be  of  especial   value  to  the 

general  practitioner  as  well  as  to  the 

specialist.    The  illustrations  are  very 

satisfactory.    Many  of  them  are  new 

and  are  particularly  clear  and  attrac- 
tive.— Boston  Med.  and  Sur.  Jour. 


This  work,  which  has  already  gone 
through  five  large  editions,  and  has 
been  translated  into  French,  Ger- 
man, Spanish  and  Italian,  is  the 
most  practical  and  at  the  same  time 
the  most  complete  treatise  upon  the 
subject. — The  Archives  of  Gynecol- 
ogy, Obstetrics  and  Pediatrics. 

THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DIS- 
EASES OF  THE  URINARY  ORGANS.  Second  and  revised  edi- 
tion.   In  one  octavo  vol.  of  203  pp.,  with  25  engravings.    Cloth,  $2.25. 

THE    PATHOLOGY   AND   TREATMENT   OF   STRICTURE 


OF  THE  URETHRA  AND  URINARY  FISTULiE.  From  the 
third  English  edition.  In  one  octavo  volume  of  359  pages,  with  47 
engravings  and  3  lithographic  plates.     Cloth,  $3.50. 

THOMSON  (JOHN).     DISEASES  OF   CHILDREN.     In  one  crown 

octavo  volume  of  350  pages,  with  52  illus.  Cloth,  $1.75,  net.  Just  ready. 

TODD  (ROBERT  BENTLEY).     CLINICAL  LECTURES  ON  CER- 
TAIN ACUTE  DISEASES.     In  one  8vo.  vol.  of  320  pp.,  cloth,  $2.50. 

TREVES    (FREDERICK).      OPERATIVE    SURGERY.      In    two 

8vo.  vols,  containing  1550  pp.,  with  422  illus.     Cloth,  $9 ;  leath.,  $11. 

A  SYSTEM  OF  SURGERY.     In   Contributions  by  Twenty -five 

English  Surgeons.  In  two  large  octavo  volumes.  Vol.  I.,  1178  pages, 
with  463  engravings  and  2  colored  plates.  Vol.  II.,  1120  pages,  with 
487  engravings  and  2  colored  plates.     Complete  work,  cloth,  $16.00. 


30     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


TREVES  (FREDERICK).    SURGICAL  APPLIED  ANATOMY.  In 

one  12mo.  volume  of  540  pages,  with  61  engravings.  Cloth,  $2.  See 
Student's  Series  of  3fanuals,  page  27. 

TUTTLE  (GEORGE  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  CHILDREN.  In  one  handsome  12mo.  volume  of  about  300  pages, 
with  many  illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books, 
edited  by  Bern  B.  Gallatjdet,  M.  D.    See  p  18. 

VAUGHAN    (VICTOR    C.)    AND    NOVY    (FREDERICK    G.). 

PTOMAINS,  LEUCOMAINS,  TOXINS  AND  ANTITOXINS, 
or  the  Chemical  Factors  in  the  Causation  of  Disease.  New  (3d)  edition. 
In  one  12mo.  volume  of  603  pages.     Cloth,  $3. 


The  present  edition  has  been  not 
only  thoroughly  revised  throughout 
but  also  greatly  enlarged,  ample 
consideration  being  given  to  the  new 
subjects  of  toxins  and  antitoxins. — 
Tri-Stnte  Medical  Journal. 


The  work  has  been  brought  down 
to  date,  and  will  be  found  entirely 
satisfactory. — Journal  of  the  Ameri- 
can Medical  Association. 

The  most  exhaustive  and  most  re- 
cent presentation  of  the  subject. — 
American  Jour,  of  the  3Ied.  Sciences. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1899. 
Four  styles :  Weekly  (dated  for  30  patients);  Monthly  (undated  for 
120  patients  per  month);  Perpetual  (undated  for  30  patients  each 
week);  and  Perpetual  (undated  for  60  patients  each  week).  The  60- 
patient  book  consists  of  256  pages  of  assorted  blanks.  The  first  three 
styles  contain  32  pages  of  important  data,  thoroughly  revised,  and 
160  pages  of  assorted  blanks.  Each  in  one  volume,  price,  $1.25. 
With  thumb-letter  index  for  quick  use,  25  cents  extra.  Special  rates 
to  advance-paying  subscribers  to  The  Medical  News  or  The 
American  Journal  of  the  Medical  Sciences,  or  both.  See  p.  32. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  by  H.  Haktshorne,  M.  D. 
In  two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.  Cloth,  $9 ;  leather,  $11. 

WEST  (CHARIiES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.     Cloth,  $3.75 ;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE   NERVOUS  SYSTEM  IN 

CHILDHOOD.     In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAG- 
ING. New  (4th)  edition.  In  one  12mo.  volume  of  504  pages,  with 
502  engravings,  many  of  which  are  photographic.  Just  read//.  $3.00, 
net.     Notices  of  previous  edition  are  appended. 

work  of  ready  reference  for  sur- 
geons.— North  Amer.  Practitioner. 
The  part  devoted  to  bandaging  is 
perhaps  the  best  exposition  of  the 
subject  in  the  English  language.  It 
can  be  highly  commended  to  the 
student,  the  practitioner  and  the 
specialist. —  The  Chicago  Medical 
Recorder. 


We  know  of  no  book  which  more 
thoroughly  or  more  satisfactorily 
covers  the  ground  of  Minor  Surgery 
and  Bandaging. — Brooklyn  3Iedical 
Journal. 

Well  written,  conveniently  ar- 
ranged and  amply  illustrated.  It 
covers  the  field  so  fully  as  to  render 
it  a  valuable  text-book,  as  well  as  a 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York,     31 

WHITLA  (T^IililAM).  DICTIONARY  OF  TREATMENT,  OR 
THERAPEUTIC  INDEX.  Including  Medical  and  Surgical  Thera- 
peutics.    In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WIL.LiIA3IS  (DAWSON).  THE  MEDICAL  DISEASES  OF  CHIL- 
DREN. In  one  12mo.  volume  of  629  pages,  with  18  illustrations. 
Just  ready.     Cloth,  $2.50,  net. 

The  descriptions  of  symptoms  are  [  diagnoses,  prognosis,  complications, 
full,  and  the  treatment  recommended  :  and  treatment.  The  work  is  up  to 
will  meet  general  approval.  Under  \  date  in  every  sense. — The  Charlotte 
each  disease  are  given  the  symptoms,  i  dledical  Journal. 

WELSON  (ERASMUS).    A    SYSTEM    OF    HUMAN    ANATOMY. 

A  new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  616  pages.  Cloth,  $4 ; 
leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.    In 


one  12mo.  volume.     Cloth,  $3.50. 

WINCKEL.  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
Translated  by  James  R.  Chadwick,  A.M.,  M.D.  With  additions 
by  the  Author.    In  one  octavo  volume  of  484  pages.     Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  eighth  German  edition,  by  Ira  Remsen,  M.  D.  In  one 
12mo.  volume  of  550  pages.     Cloth,  $3. 

YEAR-BOOK  OF  TREATMENT  FOR  1892,  1893,  1896,1897  and  1898. 
Critical  Reviews  for  Practitioners  of  Medicine  and  Surgery,  In  con- 
tributions by  25  well-known  medical  writers.  12raos.,  about  500  pages 
each.  Cloth,  $1.50.  In  combination  with  The  Medical  News  and 
The  American  Journal  of  the  Medical  Sciences,  75  cents. 

YEO  (I.  BURNEY).     FOOD  IN  HEALTH  AND   DISEASE.    New 

(2d)  edition.     In  one  12mo.  volume  of  592  pages,  with  4  engravings. 
Cloth,  $2.50.     See  Series  of  Clinical  Manuals,  page  26. 


We  doubt  whether  any  book  on 
dietetics  has  been  of  greater  or  more 
widespread  usefulness  than  has  this 
much-quoted     and    much-consulted 


work  of  Dr.  Yeo's,  The  value  of 
the  work  is  not  to  be  overestimated. 
— Netv  York  Medical  Journal. 


A  MANUAL   OF   MEDICAL   TREATMENT,  OR  CLINICAL 

THERAPEUTICS.  Two  volumes  containing  1275  pages.  Cloth,  $5.50. 

YOUNG  (JAMES  K.).     ORTHOPEDIC  SURGERY.     In    one    8vo. 
volume  of  475  pages,  with  286  illustrations.     Cloth,  $4;  leather,  $5. 

In  studying  the  different  chapters,  |  surgical  specialty  and  every  page 
one  is  impressed  with  the  thorough-  i  abounds  with  evidences  of  prac- 
ness  of  the  work.  The  illustrations  ticality.  It  is  the  clearest  and  most 
are  numerous — the  book  thoroughly  modern  work  upon  this  growing  de- 
practical — Medical  News.  \  partment  of  surgery. — The  Chicago 

It  is  a  thorough,  a  very   compre-  :  Clinical  Review. 
hensive  work  upon   this  legitimate 


PEKIODICALS. 


PROGRESSIVE  3IEDICINE. 

A  Quarter]y  Digest  of  New  Methods,  Discoveries,  and  Improvements 
in  the  Medical  and  Surgical  Sciences  by  Eminent  Authorities.  Edited  by 
Dr.  Hobart  Aniory  Hare.  In  four  abundantly  illustrated,  cloth  bound, 
octavo  volumes,  of  400-500  pages  each,  issued  quarterly,  commencing 
March  1st,  1899.     Per  annum  (4  volumes),  $10  00  delivered. 


THE  MEDICAL.  NEWS. 

Weekly,  $1.00  per  Annum. 

Each  number  contains  32  quarto  pages,  abundantly  illustrated, 
crisp,  fresh  weekly  professional  newspaper. 


THE  A^IERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 

Monthly,  S4.00  Per  Annum. 

Each  issue  contains  128  octavo  pages,  fully  illustrated.     The  most 
advanced  and  enterprising  American  exponent  of  scientific  medicine. 


THE  MEDICAL  NEWS  VISITING  LIST. 

Four  styles,  Weekly  (dated  for  30  patients) ;  Monthly  (undated,  for 
120  patients  per  month) ;  Perpetual  (undated,  for  30  patients  weekly  per 
year) ;  and  Perpetual  (undated,  for  60  patients  per  year).  Each  style  in 
one  wallet-shaped  book,  leather  bound,  with  pocket,  pencil  and  rubber. 
Price,  eaxii,  $1.25.    Thumb-letter  index,  25  cents  extra. 


THE  MEDICAL  NEAVS   POCKET  FORMULARY. 

Containing  1600  prescriptions  representing  the  latest  and  most  ap- 
proved methods  of  administering  remedial  agents.  Strongly  bound  in 
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COMBINATION 

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.      10.00 

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In  Combination. 

^"^•^^[$15.00 


In  all  «i20.75  for  $16.00 
First  four  above  publications  in  combination        .        .        !g>15.73 
All  above  publications  in  combination    .... 

Other  Combinations  will   be  quoted  on  request. 
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fl33 


